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DISEASES 



OF THE 



EAR, NOSE, AND THROAT 

AND 

THEIR ACCESSORY CAVITIES. 
A Condensed Text-book. 

/ BY 

Seth Scott Bishop, M.D., LL.D., 

Professor in the Chicago Post-Graduate Medical School and Hospital; Surgeon to the Illinois Char- 
itable Eye and Ear Infirmary; Consulting Surgeon to the Illinois Masonic Orphans' Home 
and to the Silver Cross Hospital of Joliet ; Formerly Surgeon to the South-Side 
Free Dispensary and to the West-Side Free Dispensary ; Member of the 
International Medical Congress, The Pan-American Medical 
Congress, The American Medical Association, The 
State Medical "Societies of Illinois and 
Wisconsin, The Chicago Patho- 
logical Society, etc. 



Illustrated uuith One Hundred Colored Ldthographs and One hundred 
and Sixty-eight Additional Illustrations. 




PHILADELPHIA, NEW YORK, CHICAGO : ' 

THE F. A. DAVIS COMPANY, PUBLISHERS. 

1897. 






COPYRIGHT, 1897, 

BY 

THE F. A. DAVIS COMPANY. 
[Registered at Stationers' Hall, London, Eng.] 



Philadelphia, Pa., U. S. A. 

The Medical Bulletin Printing-House, 

191'", Cherry Street. 



IN RECOGNITION OF HIS DISTINGUISHED 
SERVICES 



ADVANCEMENT OF SURGERY, 
THIS BOOK 

IS 

AFFECTIONATELY DEDICATED 

TO 

PROF. NICHOLAS SENN, M.D., Ph.D., LL.D., 

BY 

THE AUTHOR. 



PREFACE. 



Frequent requests from medical students and general 
practitioners for a book on diseases of the ear, nose, and 
throat especially adapted for their needs have prompted the 
writer to endeavor to meet this demand. 

This work was designed, first, to help students in pre- 
paring for their degree ; second, for those progressive prac- 
titioners who wish to acquire the proficiency necessary to 
properly treat those patients who are unable to visit special- 
ists ; and, third, for those who are gradually exchanging their 
general practice for special work in these branches. 

The subjects are simplified and condensed so as to con- 
stitute this book a key, or introduction, to the exhaustive 
treatises already in the field. The place of the latter is not 
expected to be filled by this unpretentious book, for it was 
not intended primarily for specialists. Yet it is hoped that 
it may modestly serve their interests in bringing information 
on the subjects down to the present date, and as a work of 
ready reference. 

Several subjects are treated in greater detail than char- 
acterizes the work as a whole, for the following reasons : No 
book, equivalent to this, is now available containing the latest 
developments concerning diphtheria, the blood-serum therapy, 
the medical and surgical management of mastoid diseases y 
the most successful treatment of hay fever, the improved com- 
pressed-air instruments,' vaporizing apparatus, inhalents, etc. 
Therefore these subjects are given especial prominence. The 
opinions and experiences of a large number of eminent au- 
thorities are presented on the subjects of diphtheria, antitoxin 
therapy, and hay fever. 

Like works on general medicine and surgery, little space 
is devoted to the anatomy of the various organs. It is assumed 
that the reader either has a fair understanding of anatomy or 

(v) 



VI PREFACE. 

possesses such a book for reference.. This fact, taken with the 
use of the descriptive illustrations, permits the devotion of 
most of our pages to diseases and their treatment. The new 
atlas of colored drawings by Professor Politzer is recommended 
as an aid in these studies. 

The writer has freely consulted many books and journals, 
ami desires to fully and frankly acknowledge his very great 
indebtedness to them. Chiefly among these are the works of 
Politzer (Dodd's translation), Sajous, Burnett, Gruber, Roosa, 
Browne, Mackenzie, Ingals, Bosworth, Tuttle, the American 
Year-book, etc. 

For generous contributions of valuable figures and plates 
I am under deep obligations to Politzer, Sajous; Truax, Greene 
& Company; Holmes, and Krieger, and, for photographing, to 
Gramm, Coover, and Place. 

Commendation is due to my assistants: C. L. Enslee, for 
the laborious task of preparing the statistical table of 15,000 
cases from my clinical record-books, and A. T. Haight, for 
the article entitled " Eye Affections in Relation to Diseases 
of the Nose." 

It remains to express my sincere appreciation of the cor- 
dial co-operation and the artistic execution of the publishers' 
important part in the work by The F. A. Davis Company. 

The author indulges the hope that his labor may lighten 
the task of his readers in acquiring an understanding of the 
subjects taught. 

S. S. B. 

103 State Stbeet, Chicago, 
February 7. 1887. 






CONTENTS. 
PART I. 

DISEASES OF THE EAR. 

CHAPTER I. page 

A General Consideration of Diseases of the Ear, Nose, and Throat 

Based on a Study of Twenty-one Thousand Cases 3 

CHAPTER II. 
Examination of Patients . .... . . 12 

Instruments and apparatus. Tests for hearing. Recording cases 

CHAPTER III. 

Compressed-Air Appliances and their Uses . . . . 24 

Accurate methods of treatment with compressed air. High- and low- 
pressure devices. How to use high pressure safe]}'. The advan- 
tages of improved air-condensers over rubber bags. Details of 
treatment with air- meters, or regulators. 

CHAPTER IV. 

Methods of Producing and Using Compressed Air . 32 

The most useful devices for hand- and water- power pressure. Politzer- 
ization. Catheterization. Auscultation. 

CHAPTER V. 

Diseases of the External Ear 40 

Frost-bite. Eczema. Lupus. Gangrene. Epithelioma. Perichondritis. 
Hsematoma. Cystoma. Intertrigo. Herpes. Pemphigus. Syphilis. 
Deformities of the auricle. Hypertrophied auricle. Scroll-auricle 
and associated deformities. 

CHAPTER VI. 

Diseases of the External Auditory Canal 50 

Inspissated and impacted cerumen. Diffuse inflammation of the external 
meatus. Furuncles. Parasitic inflammation, or otomycosis. Ex- 
ostoses. Imperforate meatus. Foreign bodies in the meatus. 

CHAPTER VII. 

Diseases of the Middle Ear 62 

Injuries of the drum-head. Inflammation of the drum-head. Eustachian 
tubal catarrh. Acute inflammation of the middle ear. 

(vii) 



Vlll CONTENTS. 

i IIAPTER VIII. page 

Diseases of the Middle Ear, Continued 74 

Acute suppurative Inflammation of the middle ear. Chronic non-suppu- 
rative inflammation of the middle ear. Hypertrophic, or secretive, 
catarrh of the middle ear. 

CHAPTER IX. 

Diseases of the Middle Eae, Continued 86 

Sclerosis, or the adhesive inflammation of the middle ear. 

CHAPTER X. 

Diseases of the Middle Eae, Continued 100 

Surgical treatment of sclerosis. Mobilization of the ossicles. Incision of 
the posterior fold of the drum-head. Multiple incisions of the drum- 
head. Excision of sections of the drum-head. Division of the 
tensor tympani. Excision of the membrana tympani and ossicles. 
Stapedectomy. 

CHAPTER XI. 

Diseases of the Middle Eae, Continued . 112 

Chronic suppurative inflammation of the middle ear. Aspiration of the 
tympanic cavity. 

CHAPTER XII. 

Diseases of the Middle Eae, Concluded . . 122 

Sequels of middle-ear inflammation. Granulations. Polypi. Caries and 
necrosis of the tympanic cavity. Necrosis of the ossicles. Ad- 
hesions, cicatrices, and perforations of the membrana tympani. 
Artificial drum-heads. Deafness following suppuration. Tinnitus 
of purulent inflammation. Cholesteatoma. Facial-nerve paresis 
and paralysis. Carious processes in the temporal bone. 

CHAPTER XIII. 
Extension of Eae Diseases to the Ceanial Cavity ..... ... 136 

Meningitis. Subdural abscess. Cerebral abscess. Cerebellar abscess. 
Surgical treatment of brain-abscesses. Sinus-phlebitis and sinus- 
thrombosis. 

CHAPTER XIV. 

Diseases of the Mastoid Peocess 143 

Medical treatment. Indications and preparations for mastoid operations. 
Instruments required. 

CHAPTER XV. 

Tin. M \stoii) Opeeations 155 

The simple, or Schwartze, operation. The radical, or Stacke, operation. 
The modified mastoid operation. Abscess of the neck from middle- 
ear and mastoid suppuration. 



CONTENTS. IX 

CHAPTER XVI. page 

Diseases of the Internal Ear . . 168 

Hyperemia and anaemia of the labyrinth. Inflammation of the labyrinth. 
Panotitis. Haemorrhage into the labyrinth. Meniere's disease. 
Leucocythaemic deafness. Syphilis of the labyrinth. Diseases of 
the auditory nerve. Neuroses of the perceptive apparatus. Hyper- 
audition. Hyperesthesia. Paracusis. Paracusis Willisii. Sub- 
jective, sounds, or tinnitus aurium. Nervous tinnitus. Spasmodic 
noises. Paresis and paralysis of the auditory nerve. Cerebral 
causes of deafness. New growths of the internal ear. 

CHAPTER XVII. 

Diseases of the Internal Ear, Concluded . . 180 

Injuries of the labyrinth. Deaf-mutism. Education of the deaf. Hear- 
ing-instruments. 



PART II. 

DISEASES OF THE NOSE. 

CHAPTER XVIII. 

Examination and Instruments . . 189 

Examination of patients. Instruments. Atomizers. Vaporizers. Sprays. 
Inhalents. Inhaler. 

CHAPTER XIX. 

Diseases of the Nasal Cavities . 203 

Influenza. Acute rhinitis, or coryza. Simple chronic rhinitis. Chronic 
nasal catarrh. 

CHAPTER XX. 

Diseases of the Nasal Cavities, Continued 214 

Hay fever. The neurotic theory. Uric acid as a cause of hay fever. 

CHAPTER XXI. 

Diseases of the Nasal Cavities, Continued 231 

Hay fever, continued. Symptomatology. Diagnosis. Prognosis. Abort- 
ive treatment. Local self-treatment. Anti-uric-acid treatment. 
Hygienic measures. Symposium of medical opinions. 

CHAPTER XXII. 

Diseases of the Nasal Cavities, Continued 243 

Hypertrophic rhinitis. Galvano-cautery apparatus. Operations for 
hypertrophies. Atrophic rhinitis, or dry catarrh. Ozaena. 



\ CONTENTS. 

CHAPTEB XXIII. 

DISEASES OF THE Nasal CAVITIBS, Continued 

Epistaxls, or nose-bleeding. Mucous polypi. Fibrous polypi. Cystic 
polypi. Papillomata. Erectile tumors. Cbondromata. Osteo- 
mata. Exostoses. Rhiuoliths. Vascular tumors. Sarcomata. 
Carcinomata. 

CHAPTER XXIV. 

Diseases of the Nasal Cavities, Concluded ... 

Tuberculosis of the nose. Syphilis of the nose. Lupus of the Nose. 
Glanders. Furuuculosis. Anosmia. Parosmia. Deformities and 
diseases of the nasal septum. Blood-tumors of the nasal septum. 
Abscess of the septum. Perforation of the septum. Fractures of 
the nose. Foreign bodies in the nose. Animate objects in the 
nose. 

CHAPTER XXV. 
Diseases OF the Accessory Cavities of the Nose 

Inflammation of the antrum of Highmore, or maxillary sinus. Ethmoid 
diseases. Sphenoid diseases. Diseases of the frontal sinuses. Eye 
affections in relation to diseases of the nose. 

CHAPTER XXVI. 

Diseases of the Nasopharyngeal Cavity .... ....... 

Naso-pharyj^geal catarrh. Atrophic catarrh of the naso-pharynx. Fi- 
brous polypi of the naso-pharynx. Fibromucous polypi of the 
naso-pharynx. Malignant tumors. Adenoid vegetations in the 
vault of the pharynx. 



PART III. 

DISEASES OF THE PHARYNX. 

CHAPTER XXVII. 
Diseases of the Phabynx 305 

Acute pharyngitis, or simple sore throat. Simple chronic pharyngitis. 
Acute rheumatic pharyngitis. Chronic rheumatic sore throat. 

CHAPTER XXVIII. 

Diseases of the Phabynx, Continued 319 

throal of measles, scarlet fever, and small-pox. Follicular pharyn- 
gitis. Membranous sore throat, non-diphtheric. 

CHAPTER XXIX. 
Diseases of ire Phabynx, Continued 328 

Diphtheria. Pathology. Etiology. Symptomatology. Diagnosis. Piog- 



CONTENTS. XI 

CHAPTEE XXX. page 

Diseases of the Phaeyxx, Continued 339 

Diphtheria, continued. Treatment. Examination of diphtheric patients. 
Isolation. Local and constitutional treatment. 

CHAPTER XXXI. 

Diseases of the Phaeyxx, Continued 350 

Diphtheria, continued. Serum therapy, or the antitoxin treatment of 
diphtheria. The production and action of antitoxin. The time 
and methods for using antitoxin. The dosage. The results of 
blood-serum therapy. Symposium of opinions and experiences, 
both for and against antitoxin treatment. 

CHAPTER XXXII. 

Diseases of the Pharynx, Continued 373 

Tonsillitis. Phlegmonous tonsillitis. Hypertrophy of the tonsils. Ton- 
sillotomy. Instruments and methods of operating. 

CHAPTER XXXIII. 

Diseases of the Phaeyxx, Continued 3^9 

Mycosis, or parasitic disease of the pharynx. Concretions in the tonsil. 
Non-malignant tumors of the pharynx. Adhesions and false mem- 
branes in the pharynx. Uvulitis. Malformations of the uvula. 
Tuberculosis of the pharynx. Syphilis of the pharynx. Cancer of 
the pharynx. 

CHAPTER XXXIV. 

Diseases of the Phaeyxx, Concluded . . . 404 

Retropharyngeal abscess. Neuroses of the pharynx. Neuroses of sen- 
sation. Hyperesthesia. Anesthesia. Paresthesia. Neuroses of 
motion. Paralysis of the pharynx. Burns and scalds of the 
pharynx. Foreign bodies in the pharynx. 



PART IV. 
DISEASES OF THE LARYNX. 

CHAPTER XXXV. 

Diseases of the Laeyxx 415 

Laryngoscopy. Instruments. Apparatus. Difficulties of laryngoscopy. 

CHAPTER XXXVI. 
Diseases of the Laeyxx, Continued 4*21 

Acute laryngitis. 

CHAPTER XXXVII. 

Diseases of t^e Laeyxx, Coxtixued 428 

Croup. Comparison >f true croup with laryngeal diphtheria. 



Ml CONTENTS. 

CHAPTER XXXVIII. page 

Diseases of the Laeynx, Continued . ■ . 435 

Intubation of the larynx. Instruments, method, and results. Care and 
feeding of patients. Tracheotomy. 

CHAPTER XXXIX. 
Diseases ^v the Laeynx, Continued 446 

Chronic laryngitis. Atrophic laryngitis. Suppurative laryngitis. Ab- 
scess of the larynx. Granulations of the vocal cords. (Edema of 
the larynx. 

CHAPTER XL. 
Diseases of the Laeynx, Continued . . ............. 459 

Neuroses. Spasmodic croup. Anomalies of sensation. Nervous aphonia. 
Paralyses. 

CHAPTER XLI. 

Diseases of the Laeynx, Continued ... 468 

Tuberculosis of the larynx. Syphilis of the larynx. 

CHAPTER XLII. 

Diseases of the Laeynx, Concluded . . 477 

Tumors. Innocent tumors. Papillomata. Fibromata. Malignant 
tumors. Epitheliomata. Sarcomata. Foreign bodies in the 
larynx. 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1. Arrangement of instruments and apparatus Facing 12 

2. Pynchon's cabinet for instruments, etc Facing 12 

3. Author's light-condenser 13 

4. Spring-band mirror-holder 14 

5. The author's adjustable bracket 15 

6. Toynbee's ear-specula 15 

7. Gruber's ear-specula 15 

8. The author's massage otoscope 16 

9. The author's cotton-carrier 17 

10. Normal drum-head of right ear 17 

11. Normal drum-head of left ear . 17 

12. Outer surface of the left tympanic membrane of an adult 18 

13. The author's automatic tuning-fork 20 

14. Galton's whistle 22 

15. Politzer's acoumeter 23 

16. The author's original compressed-air meter 25 

17. Davidson cut-off 26 

18. Hand-dilator and combined air-reservoir and hand-pump 33 

19. Hydraulic pump 34 

20. Hand air-pump . . 34 

21. Air-meter of improved pattern 35 

22. Politzer's air-bag 35 

23. Buttle's inflator 36 

24. The author's improved inflator * 36 

25. Eustachian catheter 36 

26. Vertical section of the naso-pharynx with catheter introduced into Eustachian tube 37 

27. Fixation of the catheter with the left hand 38 

28. Toynbee's auscultation-tube 39 

29. Gangrene of ear ; mastoid operation 43 

30. Hypertrophied auricle 46 

31. Alpha syringe 52 

32. Author's small powder-blower 54 

33. Rupture of the anteroinferior half of the drum-head caused by a box on the ear . . 62 

34. Section through the tympanic membrane, malleus, and upper and outer tympanic wall 

of a decalcified preparation 63 

35. Eustachian tube and tympanic cavity 65 

36. Radiate vascular injection of the drum-head 69 

37. Radiate vascular appearance in acute inflammation of the middle-ear 70 

38. Convexity of the drum-head due to pressure from within 74 

39. Nipple-shaped bulging of the posterior portion of the drum-head, on the siirnmit of 

which is the perforation 77 

40. Fluid effusion in the tympanic cavity, marked by a bright line 79 

41. Circumscribed bulging of the drum-head due to pressure of fluid in the middle ear . . 79 

42. Great concavity of the drum-head and foreshortening of the hammer-handle SO 

43. Semilunar chalky deposit in front of the handle of the mallet 87 

44. Niche of the fenestra ovalis, with the crurse of the stapes, in the normal ear of an 

adult 87 

45. Marked retraction of the drum-head 92 

46. Circumscribed depression in the anteroinferior quadrant of the left drum-head ... 92 

47. Circumscribed adhesion of the membrana tympani to the promontory underneath the 

handle of the mallet 92 

48. The author's ossicle-vibrator 100 

49. Section of the posterior fold of the membrana tympani 101 

50. Internal surface of the left membrana tympani 102 

51. Vertical section of the external meatus, membrani tympani, and tympanic cavity . . 103 

52. Triangular resection of the drum-head 103 

53. Middle-ear instruments and handle 107 



(xiii) 



\iv LIST OF ILLUSTRATIONS. 

PAGE 

64 Th6 author's ossicle-hook 108 

Politser'e pineette 108 

■tensive destruction of the drum-head 112 

57. Pear-shaped perforation of the drum-head 113 

'erf oration of the posterior half of the right drum-head 113 

-unction of the inferior half of the membrana tympani, laying bare the promon- 
tory and niehe of the round window 113 

irge perforation of the right drum-head 113 

t'd. Destruction of inferior half of the drum-head. Globular granulations on the inner 

wall of the middle ear 115 

be author's large powder-blower 118 

ti:i. The author's ear-aspirator 121 

61 Politser's polypus-forceps 123 

The author's middle-ear ease 123 

66. The author's eanstie applicator on flexible shank 124 

ertical section of middle ear ; drum-head in contact with the inner wall 125 

ml-like cords between the lower end of the hammer-ban die and the stapedo-incudal 

articulation 125 

entral perforation of the drum-head and calcareous deposits 126 

To. Appearance in facial paralysis, the patient laughing Facing 130 

71. Same as Fiir. 70, three months after Stacke operation and treatment with electricity. 

Facing 130 

72. The author's ear-electrodes, attached to band 131 

73. Sequestra of dead bone, and the ossicles. Actual size Facing 132 

74. Post-mortem section of the temporal bone, showing a perforation of the lateral 

sinus Facing 132 

7"). The author's middle-ear curette 134 

76. Horizontal section of the ear 135 

77. Interior of base of skull Facing 143 

78. The author's aural ice-bag . . . . .- 147 

79. Back's mastoid knife 148 

80. J. B. Hamilton's scalpel 150 

tuck's mastoid chisels 150 

82. The author's long mastoid gouges 151 

83. Lead-filled mallet 151 

84. The author's set of curettes 152 

85. The author's mastoid guide 152 

86. Mathieu's tongue-holding forceps 152 

87. The author's periosteum separator 153 

B8. The author's double retractors 153 

89. Side-view of a skull, showing opening in mastoid process for Schwartze operation. 

Facing 156 

Schwartze operation Facing 156 

91. Horizontal section through right temporal bone 156 

92. Opening of the antrum 157 

93. Horizontal section through right temporal bone, showing distance between lateral 

Sinus and external canal 158 

B4. Horizontal section through right temporal bone, cut near centre of external meatus 159 

Perpendicular section through right temporal hone 160 

96. Adhesive-plaster dressing for mastoid wound Facing 161 

J7. lane of incision healed two months after a Schwartze operation Facing 161 

98. The Stacke operation completed 162 

Side of skull, showing Stacke operation Facing 162 

100. Vertical section through the ear Facing 162 

10L Horizontal section of temporal hone, cut near floor of external meatus 164 

102. Six weeks after Stacke operation Facing 164 

ppearance two weeks after a modified operation. Healed five weeks after operation. 

Facing 164 

104. Post-mortem section of mastoid process Facing 166 

L05. Appearance three weeks after a modified Stacke, and an operation for a neck-abscess. 

Facing 166 

L06. The conical conversation-tube 185 

107. The London horn 185 

' lectric [nominator 189 

LOO. Lngals' nasal speculum 190 



LIST OF ILLUSTRATIONS. XV 

FIG. PAGE 

110. The author's nasal speculum 190 

111. Bosworth's tongue-depressor 191 

112. Throat mirrors 192 

113. White's palate-retractor 192 

114. The rhinoscopic image 193 

115. Hard-rubber palate-elevator 193 

116. Davidson spray 194 

117. DeVilbiss universal spray 194 

118. Lavolin atomizer 195 

119. Truax, Greene & Company's atomizer 196 

120. The universal vaporizer 196 

121. The globe nebulizer 197 

122 to 127. Methods of receiving sprays and inhalents 198 

128. The author's camphor-menthol inhaler 201 

129. Goodwillie's nasal dilator, or tube 213 

130. Nasal synechia Facing 243 

131. Posterior view of osseous bridge shown in Fig. 130 Facing 243 

132. Flemming cautery battery 245 

133. Truax storage battery 246 

134. Cautery electrodes 247 

135. Cautery knife 247 

136. American cautery handle, with windlass 247 

137. Hobby's steel snare 250 

138. The author's septum-knife 251 

139. Webster's nasal saws 251 

140. Bellocq's cannula introduced 257 

141. Biting curette 259 

142. Casselberry's saw-tooth scissors 259 

143. The author's nasal supporter 265 

144. Hartman's forceps ' 274 

145. Dissection showing nasal duct and its relations 282 

146. Ducts connecting the nose with the accessory sinuses and the eye 286 

147. Tear-gland and drainage 288 

148. Mouth-breather Facing 298 

149. F. C. Greene's mouth-gag 299 

150. Position of child for adenoid operation or intubation ; mouth-gag introduced 300 

151. Gottstein's ring-curette 300 

152. Diphtheria bacilli 329 

153. Diphtheria bacilli 330 

154. Streptococcus pyogenes 331 

155. The author's tonsillotome, with excised tonsil 383 

156. Adhesion of soft palate to the posterior wall of the pharynx Facing 391 

157. Destruction of velum palati Facing 397 

158. Mackenzie's lateral throat- forceps 411 

159. DeVilbiss illuminator 416 

160. O'Dwyer's intubation-tubes 435 

161. Scale 435 

162. O'Dwyer's introducer, with tube attached 436 

163. O'Dwyer's extractor 436 

164. Roswell Park's aluminium tracheal tube 442 

165. Hard-rubber tracheal tubes 442 

166. Cohen's sponge- or cotton- holding forceps 452 

167. Tobold's set of six forceps, knives, etc 479 

168. Mackenzie's antero-posterior laryngeal forceps 480 



PART 



Diseases of the Ear 



CHAPTER I. 

A GENERAL CONSIDERATION OF DISEASES OF THE EAR, 
NOSE, AND THROAT BASED ON A STUDY OF TWENTY- 
ONE THOUSAND CASES. 

The following statistical tables represent the records of 
21,000 cases treated during the past seventeen years at the 
Illinois Charitable Eye and Ear Infirmary in Chicago. The 
first table formed a part of a report made by the author to the 
Ninth International Medical Congress in 1887 ; the second was 
compiled for me by my assistant, Charles L. Enslee. A rela- 
tively small number of unselected cases have been added from 
the records of my private practice to supply the place of those 
whose records were incomplete. The first classification was in- 
stituted for the purpose of establishing a basis of calculation of 
the influence, if any, exerted by occupation, age, or sex in the 
causation of ear diseases. The condition of each patient at the 
time he first presented himself at the clinic is given in order to 
determine the relative frequency of the different diseases. 

As is common in charity hospitals, a considerable number 
of those who applied for treatment belonged to that class of 
laboring-people who have no definite trade or fixed occupation. 
In order to facilitate investigation and simplify the tables as far 
as possible, all those occupations that were closely related to 
each other in nature and effects were grouped under one head- 
ing. For example, under the classification of clerks were em- 
braced salesmen, book-keepers, office employees, etc. ; with 
teamsters were grouped car-drivers, peddlers, etc.; cooks and 
bakers were classed together; brass-molders, iron-molders, etc., 
were classified with iron-workers ; plumbers, gas- and steam- 
fitters appear together ; such closely-allied occupations as stone- 
cutters, stone-masons, brick-layers, and plasterers, in which the 
influences and exposures are very similar, are grouped together 

(3) 



4 DISEASES OF THE EAR, NOSE, AND THROAT. 

under the head of day -la borers, — a term borrowed from the 
laborers themselves. 

The abbreviations employed are: 

\V. No., for whole number. 
Ac. for acute inflammation of the middle ear. 
A.c. s.. for acute suppurative inflammation of the middle ear. 
('. N., for chronic non-suppurative inflammation of the middle ear. 
('. S., for chronic suppurative inflammation of the middle ear. 
Ext., for diseases of the external ear. 
Int.. for diseases of the internal ear. 
I). ML, for deaf-mutes. 
P. 1}., for foreign body. 
In. C, for inspissated cerumen. 
Fur., for furuncle. 

Ac S. N., for acute suppurative with a chronic non-suppurative inflamma- 
tion of the middle ears. 

An. P., for aural polypus. 

.M. D., for mastoid disease. 

X. Ph., for naso-pharyngeal catarrh. 

Ad., for adenoid growths in the vault of the pharynx. 

Hy. T.,' for hypertrophied tonsils. 



Occupation. 


c 


< 


w 

CJ 

< 




32 

6 




a 


Miners . 


10 
10 
10 

11 

12 

13 
15 

16 
19 
20 
22 
22 
30 
31 
38 
47 
47 
58 
74 
80 
84 
85 
108 
232 
496 


1 

1 

1 

2 
2 

1 

i 

• 

l 

3 

1 
2 

3 

4 
12 

6 
17 

27 


*3 

1 

1 
1 
3 

4 
2 
2 
2 
2 
2 

I 

5 

1 
4 

u 4 

13 
19 
26 


6 
9 
5 
6 

8 

*8 

7 

10 
9 

14 
14 
10 
18 
26 
26 
28 
35 
55 
57 
54 
33 
59 
117 
300 


4 
1 
1 
3 
2 
2 
3 
1 
3 
5 
1 
4 
12 
8 
3 

10 
9 
12 
18 
8 
11 
23 
19 
39 
77 


l 

5 

3 
1 
4 

I 

2 
5 
6 
5 
3 

6 

10 

6 
9 

36 
60 




Firemen 




( 'oopers 




Butchers 




Packing-house laborers . . 

Engineers .... . . 


1 


Cigar-makers 




Plumbers 




Boiler-makers 

Tinners 

Shoe-makers 


1 


Bakers 




Printers 


1 


Tailors . 


1 


Blacksmiths 

Painters • • 

Sailors ... 


1 

1 

2 


Railroad-laborers 

Farmers . . 

Carpenters .... 


1 

2 


[ron-workers 

Teamsters 


1 


Factory-hands 

Clerks 

Day-laborers .... 


2 
4 
6 


Totai 


1590 


85 


109 


922 


279 


171 


24 



GENERAL CONSIDERATION. 



Summary. 





6 


Ac. 


X 

< 


* 


w 
'J 


Ext. 


►^ 




Adult males without occupation . . . 


810 
1662 
557 
562 
243 
276 
1590 


43 
75 
35 

32 
11 

11 

85 


31 
03 
28 
22 
21 
26 
109 


485 
1070 

230 

225 
41 
45 

922 


197 46 
317 106 
205 34 
232 35 
125 26 
139 38 
279 171 


7 
27 
19 
11 
8 
9 
24 


1 
4 


Boys, 6 to 15 years . 

Girls, 6 to 15 years 

Boys under 6 years . 

Girls under 6 years 

With occupations 


6 

5 

11 

8 


Total ...... ... 


5700 


292 


300 


3018 1494 456 


105 


35 


Percentage of W. No 




5.1 


5.3 


53. 


20. 8. 


2. 


0.0 



The combined tables show that, of the 21.000 cases, there 
are 11,167 patients with occupations, classified under 28 head- 
ings. Of this number, 3813 had out-door and 7354 in-door 
work. In the first table a larger proportion would undoubt- 
edly have appeared as belonging to in-door occupations, had as 
much care been exercised in eliciting the exact nature of the 
vocations of so-called day-laborers as was used during the time 
covered by the second table. About 34 per cent, are out-door 
and 66 per cent, in-door occupations, or about twice as many 
in-door occupations as out-door. 

The largest number of any one class were in-door workers, 
— 3014 domestic servants. Next in order were about half that 
number of the out-door class, or 1493 day-laborers. Then fol- 
low groups of the next highest numbers: 858 clerks, 460 iron- 
workers, 452 carpenters, 420 factory-workers of all kinds, and 
400 sewing-women, — all in-door occupations until we reach the 
out-door class again in going down the scale. 

While the great stores and factories furnish a large num- 
ber of patients, the homes contribute 5615 females, including 
the servants, seamstresses, and women without occupation, or 
more than one-fourth the whole number of the combined tables. 
These facts are significant when we take into account the slight 
difference between the number of males and females affected 
under the age of 15 years. Out of 6154 children under 15 



DISEASES OF THE EAR, NOSE, AND THROAT. 



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Factory workers .... 

Farmers 

Iron -workers 

Janitors 

Miners 


CO 

TJ 

co C 










s 

i 

: 


Bakers ........ 

Blacksmiths ... 

Batchers 

Carpenters 

Cigar-makers . 
Clerks 


Coopers 

Day -laborers ..... 

Domestics 

Fnoinpprs . . . 


r/ 

a 

5 




c/ 

C 

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a 

t/ 

._ 


Rail road -laborers 

Sailors 

Sewing women . . . 
Shoe-makers .... 
Tailors . . ... 
Teachers 


i 

s 

F- 


Tinners .... 
No occupation, males 
No occupation, females 
Boys, 6 to 15 years . . 
Girls, 6 to 15 years 
Boys under 6 years . 
Girls under 6 years 


< 

Eh 

O 

H 



GENERAL CONSIDERATION. i 

years there were 1484 boys and 1582 girls between the ages of 
6 and 15 years and 1641 boys and 1447 girls under 6 years. 
Of all these children 3029 were girls and 3125 boys, leaving a 
difference of only 96 more males than females under 15 years. 
Between the ages of 6 and 15 years there were 95 more girls 
than boys. Under 6 years there were 194 more males than 
females. 

Sex seems to have no influence in the production or pre- 
vention of diseases of the ear, nose, and throat. It appears 
that up to the age of 15 years both sexes suffer nearly equally. 
Possibly a reason for this may be found in the similarity of the 
lives and habits of the sexes during this early period. But the 
classes of society that afford clinical material at the medical 
charity institutions are such that necessity requires them to 
abandon the pursuit of an education at about the fifteenth year, 
and to enter upon bread-earning vocations. Thenceforth the 
divergence in habits and environments increases. The males 
are either out-of-doors more than ever or confined chiefly to 
mercantile houses and factories. The females become domes- 
tics, clerks, shop-girls, and seamstresses. 

An interesting question pertains to the relative frequency 
of diseases of the right and of the left ear, and of diseases of 
one ear as compared with diseases existing coincidently in both 
ears. The second table shows that in acute inflammation of 
the middle ear there is but a very slight difference in the fre- 
quency of involvement between the two ears, and both ears were 
affected in 43 per cent, of all the cases. In acute suppuration 
of the middle ear, again, there is too little difference between 
the two ears to take into account. In 15 per cent, of all these 
cases both ears were involved. 

In the 5809 cases of chronic non-suppurative inflammation 
of the middle ear the two sides were about equally affected, but 
a great contrast is now offered in the relative frequency with 
which both ears are involved in the various middle-ear diseases, 
for in this instance nearly 82 per cent, of all the cases presented 
bilateral aural affection. Sufficient importance must be at- 
tached to these undeniable figures in formulating our prognosis 



8 DISEASES OF THE EAR, NOSE, AND THROAT. 

\\\\en only one ear is already diseased, for it follows, almost as 
the night the day, that if one ear has become seriously affected, 
especially with the sclerotic form of dry catarrh, the other falls 
under the same destructive process. 

In chronic suppurative otitis media the two ears suffer 
nearly equally, and it appears that both ears are simultaneously 
affected in a little more than 60 per cent, of the cases. In 
3185 instances of unilateral ear diseases there was an excess of 
only 23 cases of the right over the left ear. This fact is 
mentioned particularly because the opinion has often been 
expressed that one ear was much often er affected than the 
other, some specialists believing that the right was by far the 
more frequently diseased. 

The tables show that about 13 per cent, were afflicted with 
naso-pharyngeal diseases, but the actual number would be far 
in excess of this figure. The institution being an eye and ear 
hospital strictly, not as great prominence has been given to the 
nose and throat affections as would be desirable, this part of the 
diagnosis sometimes being entered on the patients' cards instead 
of upon the record- books. 

About t 8 q of 1 per cent, had diseases of the mastoid process, 
which was nearly twice as prevalent in males as in females. 

Deaf-mutes formed about £ of 1 per cent, of the 21,000 
cases. There were three times as many males as females. 

The largest number of any one class of diseases was 8827 
with chronic non-suppurative inflammatory processes of the 
middle ear, or 42 per cent, of the whole number. Next in 
numerical order come 3664 cases of chronic suppurative inflam- 
mation, or 17 per cent. ; and the next highest number 1009 
cases of acute suppuration, or 5 per cent. 

American residences and business houses are heated in 
cold weather by dry hot air and kept at a temperature of 70° F. 
or higher. The inmates are subjected to the action of this dry 
heat, often laden with dust and noxious gases, the greater part 
of every day. The skin, consequently, is very active in its 
functions, and kept moist by free perspiration. But, though 
constant exposure renders the soldier, Spartan-like, indifferent 






GENERAL CONSIDERATION. 9 

to cold and storms, housing the body makes it tender, like the 
hot-house plant, and sensitive to sudden and extreme changes 
in the air. After working all a winter-day in a temperature of 
summer-heat, these people, with the powers of resistance reduced 
by fatigue and hunger, pass out immediately into a frigid 
atmosphere, with the temperature perhaps from 40° to 70° F. 
lower than that of the work-shop. The skin is chilled, the 
perspiration checked, and a determination of blood to some 
internal organ occurs. Naso-pharyngeal catarrh is probably 
the most frequent consequence. This result is aggravated by 
high winds and the inhalation of dust. In fact, a very large 
percentage of naso-pharyngeal catarrh is undoubtedly due to 
the irritating effects of dust, and this, operating in conjunction 
with cold, damp air, is largely responsible for the wide-spread 
existence of naso-pharyngeal catarrh among Americans. It is 
undoubtedly the most prevalent disease in the United States. 
The importance of this fact is obvious when we consider that so 
large a number of middle-ear affections originate in naso- 
pharyngeal inflammation which extends through the Eustachian 
tube to the tympanum. Critical examination of the throat 
demonstrates the existence of throat trouble in a large pro- 
portion of these cases. Hence, whatever causes a catarrh of 
the nose and throat is interesting to the otologist as a proximate 
cause of ear disease. 

The exanthemata are frequent causes of ear trouble during 
childhood, but youth seems to predispose to coryza, which is 
often a forerunner of tubal and tympanic catarrh. Children 
under 15 years of age constitute about 29 per cent., or more 
than one-fourth of the whole number of cases. Very many of 
them dated back to attacks of scarlet fever, measles, and the 
earaches and ;i running-ears " of infancy ; so that a much larger 
percentage than appears should probably be credited to the 
period of childhood. Only a small proportion of children were 
brought for treatment during the acute stage of inflamma- 
tion. Only about 10 per cent, were acute cases, leaving 90 
per cent., or nine times as many, who had not applied for 
treatment until the inflammation had reached a chronic stage. 



10 DISEASES OF THE EAR, NOSE, AND THROAT. 

Indeed, only 13 per cent, of the adults were seen in the acute 
stage. 

The tables show a large percentage of diseases of the ex- 
ternal ear. Since impacted cerumen may be regarded as a 
symptom and a consequence of chronic non-suppurative inflam- 
mation of the middle ear, due consideration should be given 
this fact in estimating the relative frequency of affections of the 
middle and of the external ear as shown in the tables. 

It may be permissible to cite a few facts that do not appear 
in the statistics, but which, nevertheless, were impressed upon 
me by a personal study of this class of patients. Although the 
whole state of Illinois contributed largely to the number em- 
braced by these statistics, a large majority were residents of 
Chicago, — a very cosmopolitan city. The foreign element 
predominates. The nationalities were not recorded except in 
resident infirmary cases, but the Irish constituted a very large 
and the French a very small percentage of our clinical material. 
The north of Europe furnishes a far greater percentage of our 
population than the southern portions. After considering the 
nationalities it will not be surprising when it is stated that the 
blondes exceed the brunettes in number. 

Another matter of interest to the etiologist, and to the 
student of sociology as well, was the conspicuous absence of 
baldness among these people, for cold draughts of air on heads 
deprived of nature's covering are considered by some authors 
as being a prolific cause of catarrh. 

This brings us to a consideration of the last topic of this 
chapter, — climatic causes. In speaking of climatic conditions 
as standing in a causative relation to these diseases, it should 
be understood that reference is had to those atmospheric con- 
ditions that are characteristic of the vicinity of the Great Lakes 
and the Mississippi Valley, although they may not be peculiar 
to it. A sudden great fall of temperature, accompanied with 
increased humidity of the air, is usually followed by an increase 
in the number of new patients with acute diseases of the ear, 
and of chronic cases with acute symptoms. These effects of 
atmospheric variations occur with such uniformity that we may 



GENERAL CONSIDERATION. 11 

predict an increase or decrease in the number of acute diseases 
with a reasonable degree of accuracy by observing the meteor- 
ological variations. Our climate is rugged, but the people born 
and reared in it do not seem to partake of its robust character. 
The altitude is low in the Mississippi Valley and the thermo- 
metric changes are sudden and great. It is not unusual for the 
thermometer to fall 20° or 30° F. or more in a few hours. 
Indeed, cold waves sweep suddenly over the country in summer- 
time, cooling the heated atmosphere so quickly and so thor- 
oughly that one must needs change from summer to winter 
clothing with haste or suffer from the chilling winds. Add to 
these causes of great circulatory disturbances the irritating 
effects of constantly-inhaled dust, which the ceaseless winds 
keep in never-ending motion, and the problem of the prev- 
alence of naso-pharyngeal, tubal, and tympanic catarrh in our 
climate is, in a great measure, solved. 



CHAPTER II. 
EXAMINATION OF PATIENTS. 

The examination of patients should be conducted so 
systematically that no discoverable pathological process can 
escape detection. Beginning with the right ear, both ears, 
both nares, and the throat should be minutely inspected. 
Patients often direct the surgeon's attention to one ear and re- 
mark that there is no trouble with the other, when examination 
reveals that both are affected in different degrees. The ex- 
aminer should not be misled, but should investigate for himself; 
otherwise lie is not in a position to do credit to himself or his 
art or do justice to his patron. 

A most convenient arrangement of instruments, illumi- 
nating and compressed-air apparatus, etc., is shown in Fig. 1, 
illustrating a corner of the author's private-treatment room 
(Professor Adam Politzer's portrait in the background). Fig. 
2 shows Edwin Pynchon's cabinet for instruments, medicines, 
and sprays. 

The aurist should sit facing the right side of his patient to 
begin the examination, with the light immediately behind the 
patient's head and on a level with his ear if it is an adult. In 
the case of a child the light should be on a level with the 
physician's eye. 

Time will be economized and labor facilitated by the use 
of an armless revolving-chair (Fig. 1) for the patient. The seat 
should be easily raised and lowered by a supporting centre- 
screw, fitted with sufficient nicety to prevent a rocking motion. 
The back should be unyielding and only high enough to sup- 
port the patient's back beneath his shoulders. After examining 
the right ear neither the physician nor the patient need rise to 
bring the left ear into the field of vision, for the patient's chair 
is easily turned half-way around, and the positions are correct 
to proceed, the lamp then resting in front of the patient. 
d'2) 








A 










111! • ^ ^ ■ 


r 










akll 


i E 






1 


We; ' 




Jj 


B^TF^Ij 






■*>^ 


M 


k JBL ■ • 



<w 



Fig. ].— Arrangement of Instruments and Apparatus. 




Fig. 2 — Pynction's Cabinet for Instruments, etc. 



EXAMINATION OF PATIENTS. 



13 



The best illumination is had from an Argand gas-burner. 
It lias not been possible to obtain an incandescent electric lamp 
that will afford such an evenly-diffused, brilliant light as the 
gas gives. The flame should be inclosed in a light- con denser 
(Fig. 3) not only to increase the effectiveness of the illumina- 
tion, but also to protect the operator's eyes. If the light is 
allowed to shine in one's eyes it contracts the pupils, interferes 
with perfect vision, and eventually impairs the sight. The 
condenser is constructed with a reflector instead of a lens. 
For this reason it is not top-heavy and requires no spring to 
hold it in place. By a slight stroke of the finger-nail or a 
probe, its position can be instantly 
varied without burning the finger. It 
fits over the Argand gas-burner or the 
large railroad-burners on oil-lamps. 
A special large size is made to fit the 
Welsbach light. 

The three-inch forehead-mirror is 
worn over the eye that is next to the 
light, and the aperture in the mirror 
should fall opposite the pupil engaged 
in inspecting the ear, so that both eyes 
are shielded from the direct rays of 
light. Except in case of a far-sighted 
person, the drum-head is seen with one 

eye only at a time ; so that the other eye may be kept closed. 
The mirror is best held in position by a self-retaining holder, 
like the spring head-band shown in Fig. 4. This has the 
advantage of never deteriorating or becoming soiled, and, with 
properly-adjusted spring, it does not occasion the wearer a 
headache. It leaves the hair unruffled and is in every way 
more satisfactory than the cloth or rubber bands. The fore- 
head-plate is lined with soft rubber, which renders it agreeable 
to wear and easy to cleanse. 

The light should be adjustable to the varying positions 
and heights of patients. To accomplish this the author devised 
the lamp-bracket illustrated in Fig. 5. The lamp is easily 




Fig. 3-The Author's Light- 
con denser. 



14 



DISEASES OF THE EAR, NOSE, AND THROAT. 



adjustable to any point lying within a perpendicular line two 
feet in length, and it will swing through the arc of a circle 
having a radius of three feet. The light may be placed either 
within a few inches of the surface to which it is attached or at 
a distance of three feet from the wall. To raise or lower the 
light it is necessary only to press the brake toward the arm 
above it, set the lamp at any desired level, release the brake- 
handle, and it then sets automatically. The gas is carried to 
the burner through a rubber tube, and where there is no gas 
an oil-lamp is substituted for the Argand burner. 

The metallic ear- 
specula are preferable to 
the hard rubber, but they 
should be warmed, espec- 
ially in cold weather, before 
inserting. The small end 
of the funnel should be 
oval, to correspond with 
the contour of the meatus. 
Toynbee's set of three sizes 
of short length are satis- 
factory (Fig. 6). The 
flanged border should be 
milled. Gruber's (Fig. 7) 
are also excellent, but they 
should be milled like 
Toynbee's to render them less slippery. The auricle needs to 
be drawn upward, outward, and backward in most cases to 
straighten the canal while the speculum is introduced, but in 
children it is sometimes necessary to draw the auricle downward 
and backward. 

A massage otoscope should be employed for diagnostic 
purposes as well as for treatment. In no other way can it be 
determined how much mobility of the ossicles has been lost and 
how much is regained as the result of treatment. In 1887 the 
author devised the instrument shown in Fig. 8. It consists of 
a pneumatic chamber, a concave perforated mirror, and a lens, 




FlG. 4.-SPHL\G-KA>'D MlRKOR-IIOT.DER. 



EXAMINATION OF PATIENTS. 



15 



contained in a cylinder to which is attached forty-six centi- 
metres (eighteen inches) of soft-rubber tubing and a diminutive 
air-syringe. The apex of the funnel is covered with a section 
of soft-rubber tubing to allow of its being fitted hermetically 







\:'^./.:~:.7t:'Z-Zu: ::!:Tu:::!^:.,ir7m 



^a.- 



Fig. 5.— The Author's Adjustable Bracket. 

into the external auditory canal without causing discomfort. 
The mirror focuses the light upon the drum-head, and the 
syringe alternately rarefies and condenses the column of air in 
the air-chamber and meatus. The lens in the eye-piece gives a 




1RAUX, 6BEENE k CO. 

O O o 

Fig. 6.— Toyxbee's Eak-specula. 




OO o 

Fig. 7.— Gruber's Ear-specula. 



clear view of the drum-head and mallet under brilliant illumi- 
nation and passive motion. By holding the otoscope with the 
axis of its cylinder at a right angle to the source of light, the 
rays are projected upon the drum-head. The easiest method is 
with the operator standing in front and a little to one side of 



1() 



DISEASES OF THE EAR, NOSE, AND THROAT. 



the patient, the otoscope in the left hand for the right ear, and 
the right hand with the pump on the top of the patient's head. 
The position is reversed for the left ear. As soon as the light 
is thrown through the funnel the otoscope must be held steadily 
in its relation to the lamp, and if the drum-head is not in the 
field of vision the hand upon the patient's head must tip or turn 
his head until the drum is brought into view. Now the sight 
is fixed upon the hammer, while the piston-rod is drawn out- 
ward sufficiently to produce an outward excursion of the drum- 
head. Then it is pushed inward to condense the rarefied air 
and move the membrane inward. While these movements are 




iG.8.— The Author's Massage Otoscope. 



being effected it is observed whether the mallet moves with the 
drum-head or not, and, if it does, how much freedom of move- 
ment is present as compared with the normal mobility. In i 
some old cases of sclerosis the mallet remains entirely motion- 
less, while the membrane about it vibrates. In the normal ear 
both move freely in response to every inward and outward 
motion of the air-piston. 

No more force should be applied than is necessary to 
obtain the natural excursion of the drum-head and mallet, and 
ordinarily no discomfort is caused unless the funnel is pressed 
very firmly against the canal-wall. If a deep blush overspread 
Shrapnell's membrane and the mallet, the procedure should 



EXAMINATION OF PATIENTS. 



17 



cease for the time, so as not to occasion too great hyperaemia. 
The forehead-mirror is not used with this instrument, since it 
contains its own mirror. Care mnst be taken to not allow the 
fingers to shade the reflector. 

Cotton-carriers are best made of soft silver, with round, 
twisted handle and roughened tip to engage the cotton (Fig. 9). 
It should be very delicate, so as to consume as little space as 
possible in addition to the cotton twisted upon it. In many 

Fig. 9.— The Author's Cotton-carrier. 

instances cerumen or discharges have to be removed before the 
drum-head can be inspected. The cotton-carrier usually suf- 
fices, but the beginner must be reminded that the drum is more 
superficial in infants than in adults, and in no case should the 
membrana tympani be bruised. 

The novice ought to accustom himself to the appearance 
of the normal drum by inspecting patients who have healthy 
ears. Students may profitably study each other. The healthy 





Fig. 10. 



-Normal Drum-head of Right 
Ear. (After Politzer.) 



Fig. 11.— Normal Drum-head of Left 
Ear. (After Politzer.) 



drum-head (Figs. 10 and 11) has a pearly-blue tint, is trans- 
lucent, lustrous, and always presents a triangular reflection of 
light, the apex of which is at the lower extremity of the mallet- 
handle. This luminous triangle extends downward and for- 
ward toward the periphery of the antero-inferior quadrant of 
the membrane. The long leg of the anvil can often be seen 
extending downward and backward to articulate with the 
stirrup, the posterior leg of which is sometimes visible running 



18 



DISEASES OF THE EAR, NOSE, AND THROAT. 



upward and backward, both together forming a V-shaped figure 
posterior to the upper portion of the hammer-handle. Ex- 
tending from the short process of the mallet, which is a yellow,* 
dot-like projection of the upper end of the handle, are two 
nearly horizontal folds stretching forward and backward to the 
peripheral attachment of the membrane and separating the tense 
lower section from the membrana fiaccida, or ShrapnelPs mem- 
brane, above (Fig. 12). 

For convenience of description the drum-head is divided 

into four sections by a projec- 
tion of the axis of the handle 
of the mallet to intersect the 
circumference of the membrane 
above and below and an hori- 
zontal line intersecting the 
drum-head at its centre. 

Diseased appearances are de- 
scribed in their proper chapters. 

Tests for Hearing. 



s ms s 




Fig. 12.— Outer Surface of the Left 
Tympanic Membrane of an Adult, 
Enlarged Three and One-half 
TI3IES. (After Politzer.) 

v, segment of the tympanic membrane 
lying in front of the handle of the malleus ; 
h, posterior segment of the tympanic mem- 
brane ; s, s, Prussak's striae, passing from 
the short process of the malleus to the 
spina tymp. post, et minor; ms, membrana 
Shrapnelli. 



It is difficult to test the 
hearing of one ear in such a 
manner as to exclude entirely 
the perception of the test by the 
other, except in the employ- 
ment of very delicate sounds, 
like the ticking of a watch. 
Even this ticking may be heard by the opposite ear when 
it is normal. The watch-sounds are the most constant in 
intensity, the most convenient at hand, and therefore the most 
universally used. The same side of the same watch should 
always be employed, since the variations in pitch and volume 
are great in different watches, and there is sometimes con- 
siderable difference in the loudness of the sounds emitted from 
the opposite sides of the same watch. Many tests should 
be made with adult persons of normal hearing to fix the 
average hearing-distance for any test-watch. This distance 



EXAMINATION OF PATIENTS. 19 

usually varies from 30 to 60 inches (76 to 152 centimetres), 
and fixes the denominator of the fraction that expresses the 
hearing-power of any tested ear. The number of inches or 
centimetres at which the watch is heard gives the numerator. 
For example : A patient hears my 30-inch (76 centimetres) 
watch only 10 inches (25 centimetres) with his right ear and 
only 6 inches (15 centimetres) with his left. We record the 
watch-test as follows: H. D. R., £# (ff); H. D. L., ^ (H)l 
which reads : Hearing-distance for right ear is -J-J, or ^ of the 
normal ; for the left ear, ^\, or ^ of the normal distance. 

During the test the patient must keep his eyes closed, to 
eliminate the element of imagination. The watch should 
always be brought slowly from a distance toward the ear until 
the patient indicates that he distinctly hears the sound. This 
process needs to be repeated several times until it is demon- 
strated beyond doubt that he perceives the sound at the same 
point repeatedly. 

If the watch is not heard by bone-conduction it is brought 
into contact with the auricle, and if heard there the hearing 
is expressed as follows: -£$ (y%), meaning contact for the watch. 
If not heard until pressed against the mouth of the meatus, it 
is recorded thus : ^ (fir)? — pressure for watch. In case the 
watch cannot be heard at all it is written : ■£$ (yV). In young 
persons it can be heard by bone-conduction in contact with the 
mastoid process, upper teeth, forehead, etc., but it is not likely 
to be perceived from these points of contact by persons over 
40 years of age. Great patience is required in testing chil- 
dren's hearing, for they quickly answer in the affirmative 
whether they hear the test-sound or not, especially when they 
can see the source of sound. 

Tuning-forks are necessary in making a differential diag- 
nosis between diseases of the transmitting and the receiving- 
apparatus, and in cases where the watch-sounds are not heard. 
If but one fork is used it is better to employ one of 512 vibra- 
tions per second, — the universal standard of pitch. This is C 
one octave above middle C of the piano. It gives off fewer 
overtones, or harmonics, if the ends are rounded than if square, 



20 



DISEASES OF THE EAR, NOSE, AND THROAT. 



and if the vibrations are caused by an automatic hammer 
attachment (Fig. 13), producing a moderate and unvarying- 
blow. Some are made with sliding clamps to prevent overtones 
and to raise and lower the pitch. 

The fork-test is made by air-con- 
duction similarly to the watch-test. 
For bone-conduction it is placed with 
the end of the handle resting on the 
mastoid, vertex, upper teeth, or fore- 
head, with the shaft at a right angle 
to the bone-surface. The distance is 
recorded in terms of inches or metres, 
and the duration of the perception of 
sound is taken in seconds. Knowing 
the average distance and duration for 
a given fork, the amount of loss or 
gain in the hearing-power can be quite 
accurately recorded. Hartmann's set 
of fiYe forks are tuned to 128, 256, 
512, 1024, and 2048 vibrations per 
second. They are the C's of four 
octaves upward, beginning at the C 
below middle C of the piano. In the 
fork-test especial care must be exer- 
cised to ascertain that the patient dis- 
tinguishes between the musical note 
and the mere tactile perception of the 
mechanical vibrations. The latter can 
be perceived by the fingers as well as 
by the skull. The percussion-stroke 
must also be distinguished against. 

The fork must not be held with 
an edge of its branches opposite the meatus ; and the fork 
should not be brought to the meatus from before backward or 
from above downward, otherwise the interference of sound- 
waves in those positions extinguishes the sound. 

Weber's Test. — In normal ears the fork is heard better 




V 



Fig. 13.— Tiik Author's Auto 
matic Tuning-fork. 



EXAMINATION OF PATIENTS. 21 

when ill contact with the skull if the auditory canals are closed. 
If one ear is closed by the ringer the sound is intensified. 
This phenomenon is probably due to increased resonance of an 
inclosed space and obstruction to the exit of sound-waves. 
This has been observed in adhesions, when the middle ear con- 
tained fluids, and when the drum-head was relaxed. 

Rhine's Test. — Air-conduction is superior to bone-conduc- 
tion normally. The fork is heard before the meatus twice as 
long as on the mastoid. When the vibrations cease to be 
heard on the bone, if the fork, yet vibrating, is brought to the 
mouth of the meatus, it will again be heard by the normal ear. 
If the fork is heard longer by bone there is trouble in the canal 
or middle ear. If the hearing is impaired equally for air- and 
bone- conduction, there is labyrinthal trouble. Lesion of the 
transmitting apparatus is shown by (1) gradual loss of percep- 
tion of both lowest and highest notes ; (2) by bone-conduction 
becoming relatively better than air-conduction. Labyrinthal 
disease is characterized by (1) no alteration in the relative 
acuteness of perception of sound by air and bone, both being 
diminished ; (2) by deafness for some tones, generally the 
higher. 

Bing's Test. — After the sound of the tuning-fork vibrating 
on the median line of the vertex or forehead ceases to be heard, 
if the external canal is then closed by the finger the sound will 
be again perceived for a time by the normal ear. If this time 
is too brief, it indicates trouble in the transmitting apparatus. 
If this interval of secondary perception is normal, an existing 
ear disease must be referred to the labyrinth or nervous centres. 

GelWs Test. — The mobility of the stirrup may be deter- 
mined by condensing the air in the external meatus while the 
tuning-fork is vibrating on the head. If the stirrup is movable 
the sound of the fork is heard less distinctly or not at all during 
condensation, and dizziness or even vertigo may result. The 
condensation of the air may be produced by the pneumatic 
otoscope (Fig. 8) or by a rubber bag with an olive nozzle. 

Galton's Whistle. — This is useful in determining the loss 
of perception for the highest notes in cases of bilateral ear 



22 DISEASES OF THE EAR, NOSE, AND THROAT. 

diseases. If one ear is affected but little or not at all, the 
whistle-sounds can scarcely be excluded from it. This instru- 
ment (Fig. 14) has a compass of about three of the highest 
octaves. 

Politzer's Acoumeter. — This is an instrument of precision, 
which can be heard at a distance of forty-nine feet (fifteen 
metres) by the normal ear (Fig. 15). It is used very much like 
the watch directly opposite the opening of the canal, and the 
hearing-distances are recorded similarly to those of the watch. 
It is held by the thumb and index ringer resting in the semicir- 
cular plates, the thumb below, while the percussion-hammer is 
struck with the second finger. The cylinder which it strikes is 
tuned to C. To test bone-conduction the metal disc projecting 
from the perpendicular column is placed in contact with the 




Fig. 14.— G Alton's Whistle. 



mastoid process or the temple, while the meatuses are closed. 
I have observed that in sclerosis a patient may not be able to 
hear the acoumeter by air-conduction, although he hears all of 
Hartmann's forks. 

Speech-test. — This would be the ideal test were it not that 
no two voices are of the same pitch, volume, and timbre or 
quality. Indeed, the same voice may vary greatly at different 
times, and even at the same examination. Yet an excellent 
idea of the amount of usefulness still retained by the organ of 
hearing can be demonstrated by the speech-test. It is custo- 
mary to choose words varying greatly in the relative preponder- 
ance of vowel and consonant sounds, such as the names of 
different cities and states, and to request the patient to repeat 
these words after the examiner. In order to eliminate the 
possibility of lip-reading the patient is required to keep his eyes 



EXAMINATION OF PATIENTS. 23 

closed during the examination. Since there is a tendency to 
use the same names repeatedly, in which case patients may 
introduce the uncertain element of guessing, it is better to 
employ numerals. This gives a much wider range of sounds 
and lessens the chance of repeating the same sounds in the 
same order. Whispered speech is also used in addition to the 
low and loud tones. In advanced sclerosis and labyrinthal 
affections whispered speech cannot be interpreted. 

Vowels are heard much farther than consonants, but both 
should be used in the examination. The test should be made 
with each ear separately while the opposite one is kept closed. 
In unilateral deafness a test should be made with both ears 
sealed with the moist fingers ; if then the sound is heard as well 




Fig. 15.— Politzer's Acoumeter. 

as before, it is demonstrated that, the sound was perceived by 
the normal ear. 

Music is heard much better than speech. Many persons 
with greatly impaired hearing, unable to understand a lecture 
or sermon or the drama, can derive pleasure from an orchestra 
or opera. 

A record of every case ought to be kept in a convenient 
book for that purpose. The following headings indicate the 
method pursued by the author, the details being worked out as 
su^orested bv the characteristics of each case : — 



Date. 


Occupation. 


Particular Lesions. 


Xame. 


"Residence. 


Results of Tests. 


Age. 


History. 


Complete Diagnosis, 


Sex. 


Duration. 
Cause. 


Treatment. 



CHAPTER III. 

COMPRESSED-AIR APPLIANCES AND THEIR USES. 

By a series of experiments with the compressed-air gauge 
I have found that the maximum amount of pressure that can 
he ohtained with a Politzer air-balloon of the capacity of eight 
fluidoimces is 6 pounds ; with the six-ounce bag the pressure 
may be made to reach 10 or 12 pounds. The difference in 
favor of the smaller bulb represents the greater advantage one 
has in grasping a small object. This amount was the maximum 
obtainable by an unusually strong hand, accustomed for years to 
compressing air-bags handled at the greatest advantage for 
leverage, — that is, with the larger end of the balloon between 
the thumb and strongest fingers, and the tapering end under the 
third and fourth, or weakest fingers. As the reverse method is 
practiced by many aurists, much less force than 6 and 10 
pounds must result. 

Politzer speaks of ten- and twelve- ounce bags which are 
manipulated in Vienna by pressing them against the operator's 
side, but they are not in our markets. The Gruber balloons, 
with the opening or air- valve at the larger end, might possibly 
accumulate more force than I have mentioned, by repeatedly 
compressing them, but, on account of the valves being imperfect 
or soon becoming useless, I have discontinued their use. 
Professor Gruber himself prefers the bulb having a perforation 
in the end to be covered and compressed with the thumb. 
I have not experimented witli this kind, for one could not be 
found. 

The rubber bulb usually supplied by the Davidson Com- 
pany for hand-sprays and inflators can be made to exert 15 or 
even 18 pounds, but not by a single compression. However, 
it is not practicable to employ more than 15 pounds with the T 3 g- 
incli rubber tubing ordinarily supplied with inflators. A higher 
pressure distends it, and 18 pounds will rupture it with a loud 
report. The thick, firm, white tubes accompanying the De 
(24) 



COMPRESSED-AIR APPLIANCES AND THEIR USES. 



25 



Vilbiss atomizers will stand more, for I have tested them with 
45 pounds without even distending them. 

The force necessary to spray the nose and throat is not 
great. Eight pounds will project continuous sprays of watery 
solutions or lavolin with sufficient force from the Davidson 
atomizer. About 12 pounds' pressure is needed to produce a 
continuous and copious lavolin-spray from the De Vilbiss 
atomizer, and it requires 30 or 40 pounds to throw a spray of 
unheated glycerole of tannin. 




Fig. 16— The Author's Original, Compressed-Air Meter. 



In adapting the improved compressed-air apparatus to the 
treatment of the ear the author has endeavored to devise some 
means of determining and controlling the force and volume of 
air, or the dosage. As the illustration above (Fig. 16) will show, 
I have accomplished this by placing a pressure-gauge between 
two valves on the escape-pipe of the air-receiver. This arrange- 
ment utilizes the gauge for registering not only the air-pressure 
in the reservoir, but also the force of the current of air while it 



26 DISEASES OF THE EAR, NOSE, AND THROAT. 

is escaping at the cut-off of the treatment-tube. The cut-off that 
has proven most satisfactory is known as the Davidson (Fig. 17). 
The meter is used as follows : By opening the outer, right- 
hand valve marked 1, by turning the wheel to the left one- 
fourth of its circumference, pressing the thumb-valve of the 
cut-off, and opening valve 2, gradually you may obtain any 
number of pounds' pressure desired at the cut-off, — from 1 to 
100. To use 10 pounds: with the cut-off and valve 1 open, 
turn the valve 2 until the index needle runs up to 10. As 
long as the cut-off remains open, the needle indicates 10 
pounds. If you close the cut-off the needle rises to indicate 
the whole number of pounds in the reservoir. Now, if you fit 
a spray-producer to the cut-off and open it, the first impulse of 
the column of air, which is small in volume, is expended in 

filling the atomizer and starting the 
spray. In using the nasal bulb of the 
inflator (Fig. 24) for treating the ear 
the first impulse is expended in filling 
the nasal and superior pharyngeal cavi- 
ties in addition to inflating the middle 
ut-off. ear - The volume of air is so small 
that the needle drops down to 10 at 
once and remains there as long as the cut-off is kept open. If 
no more than this amount is desired the cut-off should be 
opened before the current is turned on and valve No. 2 should 
be slowly opened until the needle indicates the number of 
pounds required. No greater pressure will then be exerted 
unless the cut-off valve is closed. 

When it is desired to interrupt the air-current for the 
purpose of producing movements of the membrana tympani 
and ossicles, or to throw jets of volatilized medicine or sprays 
into the tympanic cavity, it is a simple matter to control the 
pressure in this way. Let us assume that we want to use, with 
the nasal-tipped inflator I have adapted to this purpose, 3 
atmospheres, or about 45 pounds. Valve 1 being opened, 
apply the cut-off to the nasal bulb containing the medicine on 
sponges; open the cut-off; turn on 20 pounds with wheel 2 and 




COMPRESSED-AIR APPLIANCES AND THEIR USES. 27 

then close the cut-off. The needle rises. Now, if the inflator is 
inserted into the nostril with the patient's nose firmly closed 
and cheeks fully distended, the instant the cut-off is opened the 
needle runs down to 20. Close the cut-off and the needle 
mounts to 45 pounds. Open the cut-off at that moment and 
the needle descends again to 20 ; close the cut-off and the 
needle rises ; the instant it touches the 45 pounds' mark open 
the cut-off again and so on ; repeatedly opening and clos- 
ing the cut-off will give repeated impulses at any given 
pressure. 

The resistance offered by the sponges is small, — less than 
one-third of an atmosphere. 

A little practice will enable any one to measure the doses 
skillfully and to give effective treatments without fatigue. 

If very rapid interruptions are required, valve 2 should be 
opened more freely than in the example given. For 45 pounds' 
maximum pressure about 30 pounds should be allowed for 
the uninterrupted current. Experience with this method indi- 
cates that not more than 60 interruptions per minute should be 
made in order to produce perceptible vibratory movements of 
the drum-head and ossicles. 

The dose of air for ear treatment varies greatly in different 
individuals. While 15 pounds might endanger the continuity 
of an infant's drum-head or one greatly weakened by disease, 
or the thin cicatricial membranes closing old perforations, I have 
often applied from 60 to 80 pounds to old, thickened, and 
hardened drum-heads without rupturing them. 

It is evident that if it require 50 pounds in some cases to 
propel sprays into the middle ear, it follows that in such in- 
stances rubber air-bags are insufficient, for they do not average 
more than 6 to 15 pounds. But with high pressure only a 
small volume should be used. I would propose the following 
rule to keep the operator within the limits of safety : The 
higher the pressure, the lower the volume should be. If the 
density of the air is greater than one wishes to use, even with 
a minute volume, it is easy to avoid the high pressure when 
using the nasal-tipped inflator, by leaving the opposite nostril 



28 DISEASES OF THE EAR, NOSE, AND THROAT. 

open during the first impulse, until the needle descends to the 
proper point. This allows the surplus air to escape by the 
opposite nostril. The same purpose is accomplished with the 
catheter by holding the catheter-tipped inflator (Fig. 16) a little 
withdrawn from the mouth of the catheter while the cut-off is 
first slowly opened. The surplus pressure then escapes at the 
junction of the inflator and catheter. 

The volume should be proportioned to the density with 
care in cases of atrophied soft palate, so as not to strain the 
muscles of the throat by too powerful inflations, especially if 
they are subject to rheumatic sore throat. 

It serves a convenient purpose to instruct patients to raise 
one or both hands every time they feel one or both ears inflated. 
This obviates the necessity of frequently using the auscultating 
tube. 

The warnings against the danger of rupturing the mem- 
brana tympani by politzerization have been freely sounded. 
The author has never ruptured a drum-head by compressed air, 
while he has seen a considerable number that were torn or 
perforated by blows on the ear. Even in men employed in cais- 
sons of tunnels, bridges, etc., where they are compelled to work in 
an atmosphere condensed under a pressure of 40 to 60 pounds, 
it is rare to find a ruptured drum-head. This may be owing to 
the fact that they are instructed to innate the ears so as to 
equalize the pressure on both sides of the membrane. In this 
connection it must not be forgotten that there is always the 
natural atmospheric pressure of nearly 15 pounds on the outer 
surface of the drum. Notwithstanding this, an eminent otol- 
ogist has asserted that drum-heads have been lacerated by Po- 
litzer's method. 

Professor Politzer says: "During thirteen years only four- 
teen cases of ruptured drum-heads are known. In the case of 
a normal membrana tympani a pressure of 45 to 60 pounds is 
required to cause rupture. In treatment, however, we apply 
only a pressure of about 8 pounds." If there were any fear of 
rupture, it could probably be prevented by firmly pressing the 
tragus into the external meatus. 



COMPRESSED-AIR APPLIANCES AND THEIR USES. 29 

As compared with the Valsalvan method of auto-inflation, 
the application of medicated nasal-tipped inflators as I have 
fitted them to the compressed-air apparatus makes an effective 
topical application of various medicaments possible without any 
active exertion on the part of the patient. In the Valsalvan ex- 
periment there is no medication of the middle ears, but simply a 
mechanical effect of moderate pressure and a probable conges- 
tion resulting from the straining effort. A. Hartman has shown 
that 4 to 8 pounds' pressure by the Valsalvan method is required 
to bulge forward a healthy drum-head. In numerous experi- 
ments the pressure averaged from 20 to 26 pounds in males 
and from 14 to 22 in females; but owing to swelling of the 
Eustachian tube or contained secretions this experiment often 
fails. 

The unwisdom of advising patients to practice the Valsal- 
van experiment has often been demonstrated by individuals who 
have come under my observation with a history of rapid failure 
of hearing owing to their habit of carrying the aurist's instruc- 
tions to excess. 

Politzer's method is far preferable. He says : " The press- 
ure for the application of my method in practice varies, as a 
rule, between 15 and 60 pounds." 

A decided advantage to both patient and operator, in the 
adaptation of the inflator to the compressed-air apparatus, lies 
in the fact that it renders it possible to treat most aural patients 
without the Eustachian catheter. 

The sponges of the inflator may be saturated with solutions 
of various remedies in lavolin, and sprays of these medicines 
can be propelled through the nose and Eustachian tubes into 
the middle ears with ease and certainty in the majority of cases. 
This diminishes the danger of syphilitic infection and of irrita- 
tion of the Eustachian orifices by the catheter. 

Gentle pressure will often accomplish this. Indeed, pa- 
tients sometimes feel a spray enter the ear from an ordinary 
hand-atomizer, especially when the cheeks are distended. By 
turning on the current of air gently and gradually increas- 
ing it, the permeability of the tube may be re-established by 



30 DISEASES OF THE EAR, NOSE, AND THROAT. 

a weak air-pressure more easily than by a sudden, forcible 
current. 

In practicing this method I have usually found the results 
most satisfactory when the patient assisted by inflating the 
cheeks and keeping the lips firmly closed. At the instant the 
nasal cavities become filled from the inflator the velum palati 
and base of the tongue press automatically upward and back- 
ward, completely closing the post-nasal space. 

When the effort to inflate the middle ears with air or lavo- 
lin-jets alone fails, it can be made to succeed by adding 6 or 
10 drops of sulphuric ether to the sponges in the inflator. The 
instant the ether enters the ears there is a decided sensation of 
coolness, followed by a glow of warmth. The stimulating effect 
can be seen also in the injected condition of the malleal plexus 
of vessels soon after the treatment. There are some instances 
in which the ears are more readily inflated during the act of 
swallowing. 

It has been suggested that these forcible air-currents might 
convey discharges into the mastoid cells, but Dr. Michael has 
'' proved that, especially with the application of strong currents 
of air, the secretion in the tympanic cavity is always propelled 
into the external meatus and not into the mastoid process." 

Occasionally one sees a case in which the current of air 
from the nasal-tipped inflator fails to open the Eustachian tube. 
Probably the anterior lip of the orifice of the tube is pressed by 
the air more firmly than ever against its fellow, closing it like a 
valve. A case of tubal stenosis resisted 90 pounds with the 
nasal bulb, but 50 pounds' pressure carried a spray into his 
middle ears through the catheter. 

Treatment by the catheter is accomplished with the inflators 
already mentioned, the catheter-tip being substituted for the 
nasal bulb. The sprays are thrown through the catheter in 
interrupted jets without imparting painful movements to the 
catheter, which is well nigh impossible in the practice of infla- 
tion with the air-bag fitted with the hard-rubber tube which is 
inserted directly into the catheter, and without any intervening 
flexible tube, as the custom is in Vienna. 



COMPRESSED-AIR APPLIANCES AND THEIR USES. 31 

Proper precaution should be taken to prevent dust from 
entering the air-reservoir, although by the author's methods all 
air entering the ears is filtered and medicated. 

Finally, these methods make the middle ears nearly as 
accessible as the nose and throat for treatment with the various 
volatile remedies and sprays. 



CHAPTER IV. 

METHODS OF PRODUCING AND USING COMPRESSED AIR. 

For a considerable time I have been using a new kind of 
instrument called a hand-dilator in connection with the com- 
pressed-air receiver, and the results have been so satisfactory 
that I have introduced it into all of my clinics. This instru- 
ment and process of administering aeriform fluids, although 
used by a few physicians since 1888, appear to be little known. 

The hand-dilator (Fig. 18) is not only different in construc- 
tion, but also in operation, from the various kinds of spray-pro- 
ducers or nebulizing inhalers. The atomized product projected 
by it is not properly a spray or a vapor until it expands in the 
open air. It is so fine, indeed, that before it leaves the glass 
container the eye cannot discern it. After its exit from the 
nozzle it expands into a beautiful floating mass that is compar- 
able to the most delicate undulating cloud. This fine nebula, 
which is produced and retained until administered under a 
higher pressure than hand-bulbs afford, may be impregnated 
with volatile or non- volatile medicaments. 

While making some experiments with the dilator I dis- 
covered that medicines three or four times stronger than patients 
would tolerate from the ordinary atomizers could be thrown into 
the respiratory passages, and even into the middle ear, without 
evoking any disagreeable symptoms. No smaller pressure than 
20 pounds or more should be employed in order to propel the 
nebula in sufficient volume and with enough force to dislodge 
tenacious secretions or crusts, to impress the nebulized remedies 
on the diseased surfaces, and to dilate the Eustachian tubes, in- 
flate the middle ears, or to open up stenosed bronchioles and 
occluded air-cells. While a pressure of 20 pounds may be 
sufficient, no injury has followed the employment of a much 
higher pressure, as the excess escapes from the lips. 

The combined pump and receiver is a very practical and 
economical form of apparatus where the pumping must be done 
(32) 



PRODUCING AND USING COMPRESSED AIR. 



33 



by hand, it being comparatively easy to obtain 50 pounds. It 
is provided with a regulating meter- valve for controlling the 
pressure by the method described in a paper read by me before 
the section on Otology and Laryngology of the American Med- 
ical Association at Detroit in 
1892. Any spray or inflator 
can be attached to the cut-off 



and employed 
manner. 



in the usual 



Ear Treatment. 

The hand-dilator can some- 
times be substituted for my im- 
proved middle-ear inflator for 
projecting strong medicaments 
into the ear. With the latter I 
never use a stronger solution 
of the camphor-menthol than 3 
per cent., while with the dilator 
I have medicated the tympanic 
cavity with the 10-per-cent. 
solution in lavolin without any 
unpleasant results. 

The nozzle is fitted into 
one nostril, while the other is 
held tightly closed, as in polit- 
zerization. The cheeks are fully 
distended with air, and the cur- 
rent is turned on from the com- 
pressed-air reservoir. The in- 
stant the nebula is felt to enter 
the ear the patient should raise 
his hand. Then the current is 

repeatedly interrupted by the cut-off so as to alternately fill the 
middle-ear with the nebula and allow it to escape. This pro- 
duces not only inflation of the tube and tympanum and motion 
in the ossicles and drum-head, but it medicates their mucous 




flg. 18.— hand-didator and combined 
Air-reservoir and Hand-pump. 



34 



DISEASES OF THE EAR, NOSE, AND THROAT. 



lining, on the same principle that we observe in medicating the 

mucous membrane of the eye, or the nose, or throat, when 

it is diseased. This, combined with the aid of the massage 

otoscope, provides an ideal treatment 
for dry catarrh of the tympanic cavity. 
When we reflect that middle-ear 
diseases are largely consequent upon 
an inflammatory action in the nose or 
throat, it becomes apparent how neces- 
sary it is to employ a thorough medic- 
inal as well as mechanical treatment 
addressed to this section of the respira- 
tory system ; otherwise we cannot hope 
to effect a permanent improvement. 

In connection with the use of com- 
pressed air the question of air-pumps 
is an important one. In a city with 
w a t e r- w o r k s 
the double-act- 
ing hydraulic 
pump is the 
best, since it 

gives about double the amount of 

pressure obtained by the single-acting 

pump (Fig. 19). It requires to be 

cleansed occasionally, or it fails to 

afford the required pressure. The 

maximum of pressure to be had in 

Chicago with a compound hydraulic 

pump averages about 45 pounds, — 

an amount sufficient ordinarily for the 

aurist, for the air is replenished as fast 

as it is withdrawn. In the country the 

surgeon must be satisfied with the hand-pumps (Fig. 20), unless 

he provides an elevated water-reservoir with sufficient head to 

furnish the pressure. The combined hand-pump and reservoir 

made by the Owens Brass and Copper Works, of Chicago, is 




Fig. 19.— Hydraulic Pump. 




Fig. 20.— Hand Air-pump. 






PRODUCING AND USING COMPRESSED AIR. 



35 



very convenient (Fig. 18). The pump is contained within the 
reservoir, which is supplied with an air-gauge, treatment-tube, 
and cut-off. The whole outfit weighs only fourteen pounds, 
which makes it conveniently portable. 

Another beautiful apparatus is manufactured by the Cleve- 
land Faucet Company. It is supplied with a modification of 
the author's air-meter that registers very accurately the pressure 
at the will of the operator and keeps it uniformly at any given 
pressure for which it is set (Fig. 21). Below 30 pounds it 





Fig. 21.— Air-meter of Improved Pattern. 



Fig. 22.— Politzer' s Air-bag. 



operates to a nicety. Pressure above this point can be used 
nearly to the amount contained in the reservoir, but not with an 
equal accuracy of regulation. Another excellent modification 
of the Bishop air-regulator is made by the Owens Company, of 
Chicago. 

Politzerization. — The aurist who is not provided with a 
compressed-air apparatus should possess a Politzer air-bag, and 
it is well to have one at hand to take the place of the air-pump 
should it fail to work. The Politzer bag (Fig. 22) is fitted with 
a nasal tip joined to the bag by eight inches of soft-rubber tube. 



36 



DISEASES OF THE EAR, NOSE, AND THROAT. 



One should also have a Buttle inflator (Fig. 23) fitted with hoth 
nasal and catheter tips. In manipulating these the same rule 
should be observed as in the use of the author's compressed-air 
inflator (Fig. 24). The axis of the nasal bulb should be par- 




Fig. 23.— Butti.e's Infi-atok. 






ailed to the plane of the floor of the nose. The object is to 
throw the column of air in the direction of the Eustachian ori- 
fice — not toward the nasal duct, through which the air is some- 
times forced, nor toward the frontal sinus. The Politzer bag 
should be grasped with the larger end between the thumb and 




Fig. 24.— The Author's Improved Inflator. 

stronger fingers, so as to be able to exert the greatest force when 
it is necessary. The rubber tube intervening between the nasal 
or catheter tip and the bag takes up the motion imparted to the 
bag by the hand and prevents painful jerkings of the tips and 
the catheter. Especially in the use of the catheter this is an 




Fig. 25.— Eustachian Catheter. 






important matter, and may prevent not only injury to the nose, 
but irritation or contusion of the Eustachian tube. The six- or 
eight- ounce bags are preferable to the larger sizes. The eight- 
ounce bag is the most useful for all purposes, and the rubber 
should be fresh, soft, and of the finest quality. 



PRODUCING AND USING COMPRESSED AIR. 



37 



Catheterization. — The soft-silver catheters are the best 
(Fig. 25). They can be easily bent to accommodate any irreg- 
ularities in the nasal passages or in the vicinity of the Eusta- 
chian tubes. It is desirable to have three sizes. As large a 
calibre as can be introduced without causing discomfort should 
be employed. To introduce the catheter, the beak of the in- 
strument is placed on the floor of the nose just posterior to the 




Fig. 26.— Vertical Section of the Nasopharynx with the Catheter 
Introduced into the Eustachian Tube. (After Politzer.) 

a, inferior turbinated bone; 6, middle turbinated bone; c, superior turbinated 
bone ; d, hard palate ; e, velum palati ; /, posterior pharyngeal wall ; g, Rosenmiiller's 
cavity ; h, posterior lip of the orifice of the Eustachian tube. 



skin-lined fossa at the entrance to the naris. At the first step, 
the handle is depressed so that the convexity of the beak will 
not hurt the arch of the nasal opening, but as soon as the beak 
rests on the floor the handle is raised and at the same time 
carried onward, bringing the main axis of the catheter to a 
parallel with the floor. As the instrument enters the nose it 
must not be forgotten that the patient involuntarily carries his 
head backward. As soon as the beak touches the posterior 



38 



DISEASES OF THE EAR, NOSE, AND THROAT. 






wall of the pharynx we withdraw the catheter about one-eighth 
of an inch, rotate it so as to turn the beak outward and slightly 
upward, and its extremity should be opposite the orifice of the 
tube. Then the hand is carried a little toward the opposite 
Bide, so as to bring the beak into the tubal opening (Fig. 26). 
With practice one can determine when the catheter rests in the 
tube by the sense of fixation imparted to the instrument. 
During this manipulation the ring on the proximal end of the 
catheter will indicate the position of the convexity of the distal 
extremity. No force need be used. In case of certain de- 
formities of the inferior turbinated bodies the catheter must be 
rotated through forty-five or ninety degrees, or more, before it 




Fig. 27.— Fixation of the Catheter with the Left Hand. (After Politzer.) 

can reach the pharynx. With the head thrown backward the 
weight of the silver catheter is often sufficient to carry it into 
the pharynx. The introduction can be facilitated by elevating 
the tip of the nose with the thumb of the left hand while the 
fingers rest on the bridge of the nose or on the forehead. 

However, with the improved compressed-air appliances at 
hand it is rarely necessary to resort to the catheter. It is des- 
tined to pass out of vogue to a certain extent, for the reason 
that air, volatile medicaments, and even fluid- vaselin sprays can 
be succes>iullv projected into the middle ears by means of the 
infiator (Fig. 24) adapted to the high-pressure apparatus. To 
the average patient this is a happy culmination of the inventor's 



PRODUCING AND USING COMPRESSED AIR. 39 

efforts, for it averts positive suffering, the possibility of infection 
and of irritative effects, and incidentally minimizes the amount 
of skill required for treatment. 

If occasion should necessitate the use of the catheter (Fig. 
27), the air-pressure must be greatly reduced. If more than 1 
or 2 atmospheres (15 to 30 pounds) be used with the catheter- 
beak not properly adjusted, there is a possibility of forcing the 
air into the submucous tissues and producing a dangerous em- 
physema. We have never seen any such results from this 
cause, but three deaths are recorded. (Since writing this, Dr. 
Thomas Faith has reported to me a case of emphysema of such 
character, with recovery.) 

An aid in both diagnosis and treatment lies in Toynbee's 




Fig. 28.— Toynbee's Auscultation-tube. 



auscultation-tube (Fig. 28). One end of the tube should termi- 
nate in a white tip and the other in a black one, the latter for 
the patient's ear. By inserting the white tip in the operator's 
ear while the black one rests snugly in the patient's meatus, any 
sound produced in the ear of the patient is perceived by the 
surgeon. Thus, when air is forced through the Eustachian 
tube and impinges against the inner surface of the membrana 
tympani, the resulting sound is conveyed along the continuous 
column of air in the patient's external canal, the rubber tube, 
and the surgeon's auditory meatus to his drum. It is not 
difficult, then, to distinguish between the free, breezy puff of air 
through a patulous Eustachian tube and the high-pitched, 
squeaking sound occasioned by a stenosis. 



CHAPTER V. 

DISEASES OF THE EXTERNAL EAR. 

The Auricle. 

There are certain injuries and diseases of the auricle that 
are not properly classed as ear affections, the treatment of which 
is conducted on general principles sufficiently amplified in works 
on surgery. Such affections and injuries as would not require 
treatment differing* from that demanded by the same conditions 
in other parts of the body will not greatly encumber our pages. 

DISEASES OF THE AURICLE. 

Frost-bite of the Auricle. — The symptoms of this condition 
are so familiar that a description would be superfluous. The 
chief object to be accomplished is to prevent a sudden disturb- 
ance of the circulation in the skin, by insuring a very gradual 
return to the normal temperature. ' This is best secured by the 
application of the aural ice-bag (Fig. 78) to the auricle after 
padding the post-auricular space for support. As the crushed 
ice melts, the temperature of the bag gradually rises until the ice 
becomes water, and the temperature of the water slowly arrives 
at the normal bodily temperature. Then the auricle should be 
dressed with a thick covering of an ointment consisting of equal 
parts of benzoinated oxide-of-zinc and carbolic-acid ointments. 
The parts should be protected with gauze or absorbent cotton. 

Eczema. — This skin disease is so common and so well de- 
scribed in general works that we may best confine ourselves to 
the subject of treatment. It is usually associated with a chronic 
suppurative inflammation of the middle ear, and is a result of 
that disease. The external canal is likely to be involved at the 
same time. The acrid, irritating discharges set up the derma- 
titis wherever they spread, even to the neck, side of the face, 
and head. So long as these discharges continue to bathe the 
skin, just so long will the treatment of the eczema prove un- 
availing. The ear must be so cleansed and kept free from pus, 
(40) 



DISEASES OF THE EXTERNAL EAR. 41 

by constant vigilance and the treatment outlined in the chapter 
on suppuration, that the discharges cease to reach the auricle 
and surrounding parts. If there are crusts, they are softened 
and removed by means of Castile soap and warm water. When 
the surface is thoroughly clean it is covered thickly with ben- 
zoinated oxide-of-zinc ointment, which must be strictly fresh and 
prepared with the purest zinc oxide. This is retained in place 
by a gauze or fine-linen dressing. In case of great itching or 
burning the carbolic-acid ointment is added to the zinc ointment 
in the proportion of one-fourth or one-half carbolic ointment. 
This acts not only as an antiseptic, but as a grateful local anaes- 
thetic also. In obstinate cases a 3-per-cent. salicylic-acid oint- 
ment of lanolin has proven rapidly curative, and the same may 
be said of the yellow-oxide-of-mercury ointment, 5 grains to the 
ounce of vaselin (1 per cent.). 

When the raw-appearing surface rapidly exudes drops of 
serum, weeping eczema, it should be gently dried by merely 
touching witli absorbent cotton without any friction, and then 
covered with aristol powder. Prompt drying and cicatriza- 
tion follows. General treatment may be needed for an impover- 
ished condition of the system, and, if so, Fowler's solution of 
arsenic is a valuable addition to internal medication. 

Lupus. — Lupus vulgaris generally attacks the auricle sec- 
ondarily to its existence in the face. Yet we have seen it con- 
fined to the auricle and external canal following, like eczema, a 
chronic suppuration of the middle ear. Brown tubercles about 
the size of a pin-head or a small pea form in the concha, about 
the mouth of the auditory canal, or in other parts of the auricle. 
They may be covered with brown crusts or scales. Sometimes 
they shrink up so as to form cicatrices, which, in turn, may break 
out later. Lupus exulcerans appears in the form of ulcers 
covered with brown crusts, underneath which is a spongy, moist, 
or bleeding surface. Nodules may be seen in the periphery of the 
ulcers and aid materially in making a certain diagnosis. There 
is no considerable pain, as a rule, nor intense itching as in 
eczema. The skin is of a darker hue than in the latter disease. 
A case in my practice, a lawyer and prominent politician of 60 



42 DISEASES OF THE EAR, NOSE, AND THROAT. 

years, resulted from a chronic suppuration of the middle ear. 
After stopping the suppuration the ulcers in the meatus and on 
the auricle healed under aristol. After three years, however, 
the disease again attacked the auricle, during his absence in the 
West, and destroyed it. (Since writing the above he has died.) 

All the diseased tissue is best removed by the curette, the 
galvano-cautery, nitrate-of-silver stick, acetic acid, etc., under 
cocaine anaesthesia, and the wound is dressed with aristol or 
iodoform covered with dry iodoform gauze. The prognosis must 
be guarded, on account of the strong tendency to recurrence. 

Gangrene. — Gangrene of the auricle is a very rare disease. 
It may arise without any assignable cause ; but any condition 
that vitiates the blood and lowers the vitality and powers of re- 
sistance in the presence of a local exciting cause, such as intense 
cold, pressure, acrid discharges, burns, destructive chemicals, 
etc., predisposes to this necrotic process. I have seen one case 
only. This applied at my clinic at the Chicago Commons Dis- 
pensary with the following history : A boy, 2 years old, had been 
an inmate of an orphan asylum five months. Two months be- 
fore I saw him a suppuration of the right ear began. Five days 
before I admitted him to the infirmary the skin covering the 
concha turned black and emitted a foul stench. Both sides of 
the auricle were necrotic, as well as the adjoining skin of the 
mastoid process. The necrotic tissue was cut away and the 
bone was found involved, necessitating a mastoid operation 
(Fig. 29). After the operation the child, in common with other 
members of his family, had measles. His brother died, and our 
patient was attacked with pneumonia, from which he died. 
The autopsy showed pulmonary tuberculosis. 

If gangrene is seen early enough, warmth should be ap- 
plied to stimulate the circulation until the necrotic tissue sepa- 
rates from the healthy; otherwise operative measures as indicated 
above an' called for. 

Epithelioma of the Auricle. — This more frequently arises 
on the auricle or in the external meatus than in the middle 
car or mastoid process. It begins with a sensation of irritation 
or itching, which the patient increases by persistent efforts to 



DISEASES OF THE EXTERNAL EAR. 43 

relieve. The development is slow at first and rapid afterward. 
The irritation is supplanted by ulceration, which, however, is 
easily distinguished from other similar conditions. While in 
lupus exulcerans the ulcer is deep, excoriating, and penetrating, 
in epithelioma the ulcerating surface is raised above the sur- 
rounding tissues, exuberant granulations often projecting to 
a considerable degree. If the lateral cervical glands become 




Fig. 29.— Gangrene of Ear: Mastoid Operation. 

infiltrated the diagnosis^ is more certain, but they are slow to 
participate. 

The ulceration may extend to the tympanic cavity, laby- 
rinth, and cranial cavity, producing facial paralysis, haemor- 
rhages, meningitis, brain-abscess, or thrombosis, and, after great 
suffering, death. The treatment consists in complete extirpa- 
tion of the diseased tissue when possible, the knife penetrating 
beyond the disease into the surrounding healthy tissue. If the 
auricle is extensively involved it should be amputated, and if 



44 DISEASES OF THE EAR, NOSE, AND THROAT. 

the cervical glands are affected they must be excised at the same 
time. Should it be necessary to invade the external meatus, 
a plastic operation may preserve its patency, which is important 
on account of the hearing. After-treatment is the same as for 

lupus. 

Perichondritis of the Auricle. — This is not a frequent dis- 
ease, but early treatment is important to prevent deformity. In 
the early stage there occurs a swelling of a part or the whole of 
the auricle, with a dusky-red surface, accompanied by heat and 
pain. I have seen the auricle increased to an enormous size by 
the effusion of a syrup-like fluid between the cartilage and the 
perichondrium. 

Treatment consists first in the application of cold by means 
of the ice-bag (Fig. 78). If there is great swelling with fluct- 
uation it must be incised, the fluid pressed out, and the cavity 
irrigated with antiseptic solutions. I have obtained the best 
results from injecting equal parts of tincture of iodine and water 
or alcohol, and applying pressure with cotton and a bandage. 

Hcematoma of the Auricle. — Othematoma is an effusion of 
blood between the cartilage and the perichondrium. . It rarely 
arises spontaneously, but is generally the result of traumatism. 
It occurs suddenly after a blow on the ear or pulling the auricle. 
It is a rather frequent occurrence in the mentally defective, and 
possibly indicates a disease of the base of the brain. Brown- 
Sequard has shown that section of the restiform body in animals 
is followed by this disease. The appearance of the tumor is 
accompanied by heat and pain. It nearly always occupies the 
anterior aspect of the auricle, and may cover a large portion of 
that surface. The natural outlines are obliterated, and in their 
place is a fluctuating, pale, bulging tumor. It may rupture 
spontaneously or suppurate, or in rare instances it disappears. 
Daring the first, or inflammatory, stage, when there are heat 
and pain, cold is indicated (Fig. 78). If an ice-bag is not ob- 
tainable, a bladder can be filled with ice or snow as a substitute. 
If the swelling does not diminish it must be incised, in one of 
the natural folds to prevent disfiguration, and emptied of its 
(•on tents. Most satisfactory results have followed washing out 



DISEASES OF THE EXTERNAL EAR. 45 

the cavity with a 5-per-cent. aqueous solution of carbolic acid, 
insufflating with aristol, and binding it with an absorbent- 
cotton compress. Randall opens the sac, curettes it, rubs with 
iodine glycerite, packs with iodoform gauze, and covers with 
pressure bandage. 

In this connection it is our duty to condemn in the 
strongest terms the brutal practice of pulling and boxing the 
ears of children indulged in by ignorant parents and teachers. 
I have seen many cases of deformities, ruptured drum-heads, 
abscesses, and deafness resulting from this inhuman habit. 

Cyst of the Auricle. — Cystoma is a tumefaction usually 
found on the anterior aspect of the auricle. Its appearance is 
similar to the blood-tumor already described, but it contains, 
instead of blood, a serous fluid, which is sometimes of a syrupy 
consistence and appearance. It arises suddenly from an 
unknown cause, without a previous injury or inflammation. 
The treatment is the same as for hematoma, — incision, etc. 

Intertrigo. — An excoriated condition of the skin en the 
adjoining surfaces of the auricle and mastoid process is of 
frequent occurrence among children of* the poor. It may be 
due to an impoverished condition of the blood, but is more 
likely to be caused by uncleanliness and the harmful habit of 
binding the ears down against the head by close-fitting caps. 
The skin denuded of its cuticle presents a red, raw, moist 
appearance, but it is smooth and without thickening, in this 
respect differing from eczema, which may be engrafted upon it. 
The trouble is aggravated by the efforts of the child to relieve 
the intense itching by scratching. The treatment is similar to 
that for eczema, except that dry applications are indicated, as in 
the weeping form of eczema. Powders are preferable, and of 
these aristol is sufficient. The binding caps must be interdicted 
and the irritated surfaces kept apart. 

Miscellaneous. — Herpes, pemphigus, and syphilis of the 
auricle are very infrequent lesions that differ in no way from 
the same affections of other parts of the cutaneous system and 
require no different treatment. Not being diseases peculiar to 
the ear, their description will be omitted here. 



4t; 



DISEASES OF THE EAR, NOSE, AND THROAT. 



DEFORMITIES OF THE AURICLE. 

Arrested and excessive development of the auricle in rela- 
tion to degeneration have heen made the subject of extensive 
investigation by E. S. Talbot, of Chicago; Spitzka, and others; 
but the discussion of this phase of the subject lies without the 
province of this book. Dr. Talbot's illustrated article, from 
which Fig. 30 is taken, will be found in the Journal of the 
American Medical Association for January 11, 1896. 

Auricular deformities may be divided for convenience into 
congenital and acquired. Congenital deformities may be classi- 
fied as correctible and irremediable. Acquired deformities fall 
under two headings: those resulting from disease and those 



IV 



om injuries. 




Fig. 30.— Hypertrophied Auricle. 



Hypertrophied Auricle. — The most common defect is the 
large, flattened, wing-like ear that stands out conspicuously 
from the side of the head (Fig. 30). This ear-mark serves as 
a butt of jest for the child's companions, and makes life a 
burden to the bearer. Its exaggerated prominence suggests its 
prototype among the lower animals, the mule-ear. The natural 
surface inequalities are diminished, the border of the helix is 
often thin and expanded, and the whole flaring pinna appears 
as if it had been subjected to constant pulling or pressure. 

While a large percentage of these cases are congenital, 
that barbarous mode of petty punishment — pulling the ears — 
may account for a certain amount of this deformity. I have 



DISEASES OF THE EXTERNAL EAR. 47 

been led to this conclusion by information elicited in many in- 
stances. The pressure produced by the tight caps so much in 
vogue with some people may be a factor. 

The treatment is operative. I have proceeded in two ways: 
by reducing the actual size of the auricle, and by effecting a 
corrective amount of adhesion between the auricle and the 
mastoid process. The first operation is done by removing an 
elliptical section of the cartilaginous frame-work and corre- 
sponding integument on the posterior surface and bringing the 
edges together with sutures, including the cartilage. The long- 
diameter of the ellipse is, of course, vertical. The cartilage 
must be dissected out without penetrating the skin of the an- 
terior surface. By making accurate measurements and marking 
the size and shape of the section to be removed, the result will 
be satisfactory. The auricle is then to be dressed with aristol, 
iodoform gauze, and the net bandage. This bandage is made 
of white mosquito-netting, moistened through just before apply- 
ing, and it dries in place like the plaster bandage. Union by 
first intention is had and the stitches are removed as soon as 
the adhesion is firm. This method is superior to the removal 
of the skin alone, in which case the resilience of the cartilage 
tends to tear out the sutures or bulge forward the anterior 
surface unduly. 

The second method is easier to practice, and I have given 
it preference for a number of years. The auricle is pressed 
against the side of the head in such a way as to give it in every 
part a little less projection than it ought to have. Now the 
line of junction is marked throughout its whole extent on both 
auricle and head. The section of skin included within these 
lines is dissected out in a thin layer so as to leave a denuded 
surface ; the edges of the wound are approximated and sutured 
with the stitches close together and penetrating the subcuta- 
neous tissues. The dressing and subsequent treatment are the 
same as after the first operation. 

This corrects a most unsightly deformity and may result in 
a beneficial influence on the temper and happiness of the patient 
for the remainder of his life. So far as I have been able to 



48 DISEASES OF THE EAR, NOSE, AND THROAT. 

learn, this method of operating had not been practiced pre- 
viously to its introduction by the author. 

Scroll-car and Associated Deformities. — There is a de- 
formity of the auricle in which the border of the helix turns 
forward and downward in a scroll-like roll. In such cases as I 
have seen the auricle is diminutive in size and does not present 
favorable conditions for an operation. In certain instances this 
condition amounts almost to obliteration of the pinna, and the 
auditory canal is absent. To illustrate, we will cite one of the 
cases reported by myself in the Tenth International Medical 
Congress held in Berlin : — 

A girl, 8 weeks old, was brought to my clinic October 10, 
1885. There was a congenital deformity of one auricle and 
absence of the external auditory meatus of the same ear. The 
auricle was rudimentary and doubled forward upon itself. It 
appeared shrunken and pinched, and had a large, hard nodule 
and several indentations in that part of the helix that corre- 
sponds to the key-stone of an arch. 

It is interesting to note, in this connection, that the mother 
attributed the deformity of the auricle to the fact that, about 
the fifth month of gestation, her elder child bit the mother's ear 
severely, at just that point that corresponds to the greatest 
auricular deformity in the baby. 

At the point where the canal ought to have been there was 
a depression or cid-de-sac that yielded to pressure, and imparted 
to the touch an impression as if there were an opening in the 
bone beneath. 

Four months later careful tests led me to believe that the 
child could hear with that ear. I operated to correct, as far as 
possible, the deformity of the auricle, and to ascertain if there 
were any bony meatus. On cutting down into the cul-de-sac 
where the canal should have been, I found nothing but a de- 
pression in the bone. No bony canal could be found, and I 
did not consider that further operative interference would be 
justifiable. However, I maintained a sufficient opening to give 
quite a respectable appearance of an external meatus. 

Virchow's Archives says: "Congenital anomalies of the 



" 



DISEASES OF THE EXTERNAL EAR. 49 

external ear and its neighborhood are to be referred to early 
disturbances in the closure of the first branchial cleft, and are 
often associated with fistulse of the other branchial clefts, cleft 
palate, and other forms of arrest of development in the facial 
bones, — as, for instance, with unilateral atrophy of the face." 

Certain acquired deformities have already been noticed in 
connection with the diseases that produce them, — perichondritis, 
etc. Treatment can hardly avail to remedy them. Those re- 
sulting from injuries must be treated on general surgical prin- 
ciples, with care to prevent any closure of the auditory canal. 
The latter subject will be presented in the following chapter. 



CHAPTER VI. 
DISEASES OF THE EXTERNAL AUDITORY CANAL. 

Inspissated and Impacted Cerumen. 

Impacted wax is a common condition that may give rise to 
serious results. It is really a symptom of disease, and often is 
provocative of other pathological manifestations. Recurring 
hyperemia or eczema of the external canal may excite the 
ceruminous glands to hypersecretion, and anomalies of the 
canal may prevent the natural process of elimination of the 
cerumen; so that for these two reasons it becomes dried and im- 
pacted. With the movements of the lower jaw, corresponding 
motion is imparted to the cartilaginous portion of the canal, 
which has the effect of working the accumulations of wax out- 
ward ; but, when the mouth of the canal is very narrow and 
when exostosis or other mechanical obstructions occur, they 
prevent the outward movement of the secretion, and it stops up 
the canal effectually. Patients often contribute to this impact- 
ing process by their efforts to cleanse the canal with towels, etc., 
at the bath. The middle ear may not be involved in the dis- 
eased process, or both parts may participate in trophoneurotic 
changes due to central causes. There may be, moreover, a 
simple desquamative inflammation with an abundant exfoliation 
of the epidermis. In these cases the ceruminous plugs consist 
of the fatty secretion, epithelial scales, hairs, etc., which are 
often horn-like in their hardness. 

Symptomatology. — The hearing may not be perceptibly 
diminished, providing the middle ear is in its integrity and the 
plug does not completely fill the lumen of the canal ; but 
sudden impairment of hearing and a stuffy sensation in the ear, 
with confusion, may supervene directly after a bath or profuse 
perspiring, occasioned by absorption of moisture and swelling 
in the plug. On the other hand, there is a gradual diminution 
of the hearing-power going on for years, and scarcely observed 
(50) 



DISEASES OF THE EXTERNAL AUDITORY CANAL. 51 

by the patient until his friends call his attention to it. Tinnitus 
often occurs, and with complete blocking of the canal, subject- 
ive noises ; autophony, or a hollow sound to one's own voice ; 
neuralgia of the ear or the temporal and supra-orbital regions ; 
numbness about the ear and side of the face, reflex cough of a 
spasmodic character, and mental dullness. Children are often 
chided for inattention or inaptitude when they are the unfortu- 
nate victims of such an ear disease. In the latter case both 
ears will probably be found to be affected. Impacted cerumen 
gives rise to even more serious symptoms, for the plug, which is, 
in effect, a foreign body, works inward until it impinges upon 
the drum-head, causing perforation or intra-labyrinthal pressure, 
vertigo, and epileptiform seizures. After a suppuration of the 
middle ear has ceased I have found these large plugs blocking 
the exit for pus when a fresh cold has set up another suppu- 
rative inflammation. In such cases the pus may burrow inward 
and fill the mastoid cells, and even seek the cranial cavity before 
it can dislodge or penetrate these stone-like plugs. Their pres- 
ence sometimes is sufficient to cause absorption of the canal- 
walls and an immense increase in the size of the canal. After 
their removal the skin beneath is often inflamed and appears 
more like mucous membrane than healthy integument. 

Diagnosis. — The diagnosis is easily made on inspection of 
the canal, for the dark-brown or black mass is plainly visible, 
obstructing a view of the drum-head. 

Prognosis. — The prognosis depends upon the condition of 
the middle ear and labyrinth. If they are healthy the hearing- 
will be restored and the subjective symptoms removed with the 
extraction of the cerumen. 

Treatment. — The treatment consists (1) in the complete 
removal of (he plug and (2) in remedies addressed to any patho- 
logical condition revealed by its extraction. If one is adept in 
the manipulation of ear instruments he can dexterously pull out 
the plug with the little lever found in the author's middle-ear 
set of instruments. It should be passed into the canal with the 
lever horizontal, next the roof, and carried far enough so that 
when the lever is turned downward it will imbed itself in the 



52 DISEASES OF THE EAR, NOSE, AND THROAT. 

cerumen. The latter may be so hard that quite a considerable 
pressure must be exerted to penetrate it, or it may be so soft 
that only a part, instead of the whole plug, will glide out with 
the lever when traction is exerted. Care should be taken not 
to produce any abrasion of the canal-wall with the lever. Those 
who are not practiced in ear-work had far better use the syringe. 
The continuous-flow rubber syringe with hand-bulb to regulate 
the pressure is the best. The glass syringes usually sold under 
the name of ear-syringes are of no account whatever for this 
purpose. The hard-rubber piston syringe is made for the ear 
with a flange to prevent its being introduced too far, but 
patients are likely to insert the nozzle so far that the flange 
stops up the canal opening, thus forcing the plug farther inward, 

or, when the plug is out, ex- 
erting undue pressure on 
the drum-membrane or even 
rupturing it. The Davidson 
alpha or omega syringe (Fig. 
31) has proved even more 
effective than the fountain 
irrigator. The stream should 
FKi. ai.-ALPHA syrikgk. be thrown so as to enter any 

space that may be seen be- 
tween the canal-wall and the cerumen, rather than against the 
centre of the plug, iis much force should be employed as the 
patient can bear with comfort, and without producing dizziness ; 
and the water must be as warm as can be easily borne, and a 
quart or more may be necessary at a sitting. The emulsifying 
and disintegration of the ceruminous mass can be much facili- 
tated by preceding the use of the syringe with an instillation of 
a 4-per-cent. solution of bicarbonate of sodium in glycerin and 
water, equal parts. The ear should be filled with this fluid 
warmed, several times during the day, allowing it to remain a 
quarter of an hour ; then the mass breaks up readily and 
washes out with the injections. The canal should afterward 
be dried, smeared with warm vaselin, and protected for a few 
days with clean cotton. Any dermatitis should be treated 




DISEASES OF THE EXTERNAL AUDITORY CANAL. 53 

according to the principles laid down under the following 
heading. 

Diffuse Inflammation of the External Meatus. 

Diffuse inflammation may be acute or chronic in character 
and may include the whole extent of the canal, although it is 
usually confined either to the osseous or to the cartilaginous por- 
tion. In my experience it more often has affected only that part 
of the meatus that adjoins the drum-membrane, and frequently 
it was limited to the superior half of the canal and invaded the 
membrana flaccida, 

Pathology. — If seen early the canal-wall presents a bright- 
red and smooth aspect. When the inflammation becomes in- 
tense and infiltration of the integument causes it to swell, the 
lumen of the canal is so encroached upon as to make an ex- 
amination of the drum-membrane difficult or impossible. The 
walls then lie in contact and even press upon each other; so that 
introduction of the smallest funnel is impracticable. When the 
membrana tympani is involved and can be seen, it may look red 
and swollen and the hammer-handle may be wholly invisible. 
A white coating of epidermis is frequently found lying loosely 
in the canal, and can be easily detached and removed in casts. 
In an advanced stage ulceration and granulations are found. 

Etiology. — The common habit of working at the ears with 
ear-spoons, hair-pins, common pins, and other hard substances 
is a prolific cause of inflammation of the canal. Instilling oil 
that becomes rancid, foreign bodies, and vegetable parasites act 
as exciting causes. 

Symptomatology. — In the first stage, or hyperemia, there 
may be no pain or impairment of function, and the patient 
remains unconscious of any unusual condition except for the 
itching. His attempts to relieve this only serve to increase the 
irritation, and, as the disease progresses, pain of a severe char- 
acter is developed. The movements of the jaw and pressure 
about the ear aggravate the pain. With the occurrence of pro- 
fuse transudation the hearing is dulled, and tinnitus and even 
vertigo may ensue. The more copious the exudation, the 



54 



DISEASES OF THE EAR, NOSE, AND THROAT. 



greater the stenosis and impairment of hearing. In very old 
cases the canal is found full of an offensive, thick, and greasy 
secretion. 

Diagnosis. — The diagnosis is not easy to make when the 
Btenosis is great. It may be impossible to differentiate between 
an affection of the canal alone and one affecting both the canal 
and middle ear. A microscopical examination of the exfoliated 
epidermis for micrococci and vegetable fungi may clear up the 
diagnosis. 

Prognosis. — This depends upon the extent of the inflam- 
matory process. It may invade the tympanic cavity and pro- 
duce suppuration. It may extend to the bony walls and even 

to the mastoid cells and cranial 
cavity, but such results are rare. 
The lumen of the meatus may be 
permanently contracted or obstructed 
by adhesive processes. But the 
usual course under proper treatment 
is favorable. 

Treatment. — If the inflamma- 
tion is very active and painful and 
the stenosis complete, the ice-bag 
(Fig. 78) should be applied. Ab- 
straction of blood by leeches may 
give relief, two being applied in 
front of the tragus. If the canal is sufficiently open to permit 
of washing it out, a 3-per-cent. hot solution of carbolic acid 
should be used until the canal is thoroughly cleansed. Then 
it should be dried with cotton without friction, and covered with 
a coating of aristol by means of the small powder-blower (Fig. 
32). If this does not stop the secretion in a few days, the fine 
boric powder should be substituted. 

Furunculosis. 

Synonyms. — Furuncle; boil; follicular or circumscribed 
inflammation of the external meatus. 

Pathology. — Furuncles are mostly limited to the cartil- 




FlG. 32. 



■Author's Small Pow- 
der-blower. 






DISEASES OF THE EXTERNAL AUDITORY CANAL. 55 

aginous portion and most frequently to the posterior or anterior 
wall of the canal. Although they may be secondary to a 
middle-ear inflammation, they are essentially idiopathic in char- 
acter. Furuncles appear singly, in groups, and in successive 
crops, and probably are due to the staphylococcus entering the 
hair-follicle or sebaceous gland, or to some trophic change in 
the nervous supply of the meatus. 

Etiology. — Any irritation of the canal predisposes to 
furuncle: foreign bodies, irritating instillations, ear-spoons, 
discharges from the tympanic cavity, too frequent syringing, and 
vegetable parasites. The same may be said of a general 
impairment of health, diabetes, anaemia, and dyspepsia. 

Symptomatology. — The onset of the attack is attended 
with a sense of fullness or itching, followed by tenderness on 
touch, pains of a throbbing character, and, as the swelling 
increases, impaired hearing and subjective noises. The pain 
becomes intense for a day or two and subsides on the ruptur- 
ing of the boil. Movements of the jaw increase the pain to 
such an extent that mastication is out of the question. When 
the furuncle is located on the anterior wall, the tragus becomes 
red, swollen, prominent, and sensitive ; when it is on the back 
wall, the swelling may be sufficient to protrude the auricle and 
simulate the appearance of mastoid periostitis. Occasionally 
the cervical glands, and the lymphatic glands over the mastoid 
process, when they are present, become infiltrated. For the first 
two or three days the fever, headache, and furred tongue denote 
a general systemic disturbance. 

Diagnosis. — This is not difficult on careful inspection with 
brilliant illumination. This disease is not likely to be con- 
founded with any other, when we consider the prominent symp- 
toms. The tender points are easily detected with the probe. 

Prognosis. — The disease usually runs its course in about a 
week, and unless successive crops occur, or unless the general 
health is impaired, the trouble is over. But it should not be 
forgotten that in certain instances the inflammation has invaded 
the tympanum, the mastoid, and even the cranial cavity. 

Treatment. — The first indication is to allay pain, for which 



56 DISEASES OF THE EAR, NOSE, AND THROAT. 

bromidia internally and cocaine locally are effective, the former 
in teaspoon fnl doses in water every half-hour or hour for an 
adult until pain ceases, and the latter in a warm, 10-per-cent. 
solution. As soon as the pain is relieved we should cleanse 
the meatus with dioxide of hydrogen (peroxide) comfortably 
warm. It can be warmed to a little above blood-heat without 
impairing its effectiveness. Its effervescent action washes out 
the canal, and its antiseptic property strikes at the root of the 
trouble. After cleansing I have found a 20-per-cent. solution 
of camphor-menthol in lavolin to exert a comforting and cura- 
tive influence. It is to some degree a local anaesthetic, anti- 
septic, and a constrictor of the capillary blood-vessels. A 
12-per-cent. solution of carbolic acid in glycerin acts similarly. 
They are applied, like the cocaine, on cotton. As soon as a 
distinct fluctuation can be made out, it should be incised deeply 
through the centre, under cocaine, and pressure exerted about 
the base to express all pus or necrotic tissue. 

Subsequent treatment consists in the application of a small 
amount of yellow-oxide-of-mercury ointment, 5 grains to the 
ounce ; salicylic-acid ointment, 3-per-cent. ; or carbolic-acid oint- 
ment. Proper treatment is addressed to the general health. 

Parasitic Inflammation of the External Meatus. 

Synonyms. — Mycosis; otomycosis; mycomyringitis; asper- 
gillus ; myringitis parasitica ; ear-mold ; aural fungi. 

Pathology. — Vegetable parasites in large variety are found 
in the auditory canal, but it is beyond the scope of this work 
to give a detailed description of the microscopical appearances 
of these fungi. For an extended study of this subject the 
reader is referred to Burnett. The most frequent varieties are 
the dark-brown aspergillus, or nigricans ; the yellow, or flaves- 
cens ; the green, or glaucus ; and the grayish black, or fumi- 
gatis. When these parasites once find lodgment in the ear 
they multiply rapidly. This usually begins upon the drum- 
head, and the growth and the resulting inflammation extend 
outward until the whole meatus may be involved. These cases 
are not often seen until they are so far advanced that the con- 



DISEASES OF THE EXTERNAL AUDITORY CANAL. 57 

dition is generally one of complete covering of the membrane 
and meatus with the mold. On removing the growth, which 
I have pealed out in a complete cast of the canal, the skin is 
red and raw in appearance, as though robbed of its epidermis. 

Etiology. — A damp atmosphere favors the growth of these 
parasites. The middle-aged and poor are the most frequently 
attacked. The common use of oils by the laity predisposes to 
this disease, as does any decomposing secretion or substance in 
the ear. 

Symptomatology. — Ear-mold may exist for a long time 
without the patient becoming aware of its presence, but when 
an active inflammation supervenes decisive symptoms develop. 
At first there is only an itching or irritation or feeling of full- 
ness, followed by pain, subjective noises, and diminished hear- 
ing. In my experience there is rarely a discharge except when 
the disease is secondary to a suppuration of the tympanic 
cavity ; but if the inflammatory action is severe a serous exu- 
dation occurs. Inspection shows in the black variety what is 
easily mistaken for a long-standing plug of inspissated cerumen 
were it not that the surface of the obstruction has a velvety or 
coal-dust appearance. In case of the yellow aspergillus, the 
parts look as though they had been sprinkled with finely- 
powdered mustard or yellow pollen. On removing the false 
membrane formed by the mold, its surface next the skin is of 
a dirty, grayish-white color. I have found this growth ingrafted 
on ceruminous plugs which required considerable time and care 
in removing. After their removal there was revealed not only 
the characteristic inflammatory condition, but an enormous ex- 
pansion of the meatus, due to pressure and the absorption of 
the canal-walls. 

Diagnosis. — Having the appearances described in mind, 
this is not difficult under good illumination, but a microscopical 
examination will set all doubts at rest. 

Prognosis.— This disease is rapidly amenable to the follow- 
ing method of treatment, a few days or weeks, at most, effecting 
a cure. 

Treatment.— The ear should be syringed with a quite warm 






58 DISEASES OF THE EAR, NOSE, AND THROAT. 

solution of bichloride of mercury in water, 1 to 5000. Enough 
should be used to dislodge and remove all cerumen, discharges, 
false membrane, and debris that the ear may contain. The 
class of people in whom the mold is found work or live in a 
dirty atmosphere, and the ears are a label of this fact. After 
absolute cleanliness has been effected, the meatus should be 
filled with warm dioxide of hydrogen (peroxide, H 2 2 ). This 
is left as long as it effervesces, then removed, and the canal is 
gently dried with absorbent cotton. Now the meatus is rilled 
with a 12-per-cent. solution of carbolic acid in glycerin for ten 
minutes; then this is removed and a saturated solution of iodo- 
form in alcohol is substituted. The carbolic acid does not 
corrode the tissues in this combination, but acts as an antiseptic, 
besides anaesthetizing the inflamed skin sufficiently to admit of 
the strong alcoholic solution being used without producing pain. 
The iodoform solution is left in the ear with the patient's head 
inclined to the opposite shoulder for ten minutes, when it is 
allowed to drain slowly out, leaving a covering of iodoform 
powder on the surface of the drum-head and walls of the 
meatus. This treatment destroys any remaining fungi. The 
canal is then dried and dusted with a coating of aristol, and 
stoppered with absorbent cotton until the next treatment on the 
following or second day. Should there be a considerable ex- 
udation of serum, boric-acid powder may take the place of 
aristol or may be added to it. If the drum-head has been 
perforated or if the mastoid cells have been invaded, suitable 
treatment, such as will be detailed in the chapters on those 
subjects, must be adapted to such complications. 

Exostoses or bony growths from the osseous section of the 
external meatus are so rare that we will not enter into their 
consideration here, except to remark that unless they occasion 
serious trouble they do not require attention ; but if they become 
obstructive they must be removed. 

Imperforate External Meatus. 

At the Tenth International Medical Congress the author 
reported four cases of complete closure or absence of the 



DISEASES OF THE EXTERNAL AUDITORY CANAL. 59 

meatus, — two traumatic and two congenital. In the two con- 
genital cases no external canal could be demonstrated. One of 
the traumatic cases was produced by a railroad accident that 
amputated the auricle, which was replaced and carelessly sewed 
over the canal to present a good appearance at the funeral ; but 
the patient recovered. A few years afterward I made a new 
canal, maintained its patency by means of a hard-rubber tube, 
and succeeded in restoring the usefulness of the organ. The 
other traumatic case was a man 32 years of age. It was caused 
by a wagon-wheel severing the auricle from the head when the 
patient was 3 years old. The same error was committed in 
stitching the auricle over the mouth of the canal. When the 
patient came for treatment there was a discharge of pus from a 
very minute fistula in the roof of what should have been the 
canal. I opened the canal, cauterized the cicatricial tissues, and 
maintained the opening by means of a vulcanite tube. In the 
two congenital cases I operated on one, a girl 6 months old, but 
found no osseous canal; in the other, an infant of 14 months, 
no operation was advised. Adhesions causing closure of the 
canal are very rare. 

Some of our authorities speak of imperforate external 
auditory canals as though they were of frequent occurrence ; 
but among the records of the Illinois Charitable Eye and Ear 
Infirmary at Chicago, embracing more than 21,000 cases of 
diseases of the ear, I found but 1 case of closure from exostosis, 
3 cases of congenital absence of the meatus, and 3 of traumatic 
closure. Of course, we have found numerous cases of narrow- 
ing, and various irregularities of the canal, from causes that are 
not uncommon. 

Foreign Bodies in the External Meatus. 

It is a common occurrence to find peas, beans, pebbles, 
and glass beads that children have introduced into their own or 
their companions' ears. We have found flies, bed-bugs, live 
moth-millers, etc„ but flies are oftener found in suppurating 
ears. It is not uncommon to find oats and other foreign bodies 
that have remained in the ears for years without provoking 



60 DISEASES OF THE EAR, NOSE, AND THROAT. 



symptoms that made their presence known. Notwithstanding 
this, a foreign hody is a menace to the integrity of the hearing 
organ so long as it remains in the canal. It may at any time 
up an inflammation either by mechanical irritation or, if it 
be an organic substance, by swelling and by decomposition. 

These bodies are easily seen if the forehead-mirror, bright 
light, and a funnel are employed. But the funnel must not be 
allowed to crowd the body down farther into the canal. In- 
sects, if alive, should either be immediately picked out with the 
delicate forceps or drowned by filling the ear at once with warm 
water. Beans, corn, peas, etc., absorb moisture and swell so as 
to completely fill the canal until their pressure becomes painful. 
They are easiest removed by passing the little sharp hook, con- 
tained in the author's middle-ear case, over the grain with the 
hook lying in an horizontal plane next the canal-roof; or, if 
there is greater space at any other point, we should choose it 
and carry the hook well over the berry, then turn the point 
toward the centre of the berry and press it firmly so as to imbed 
it in its substance. Careful traction will then extract it. Hard, 
inorganic bodies are not so easily extracted. Syringing is safest, 
with the head inclined toward the basin so that gravity will aid 
in their expulsion. They may be wedged into the meatus so 
that the current of water cannot dislodge them. Then the 
little blunt lever, instead of the sharp hook, may be passed 
behind the body and drawn upon, care being had not to allow 
it to slip over or around the body, leaving the latter behind. 
When glass beads work into the middle ear, the operation for 
extraction is not so simple a matter. I have the ornament of a 
" ruby " ring that could not be removed from the tympanic 
cavity until we had detached the auricle and chiseled away a 
section of the bony canal. The " ruby " is five-sixteenths of 
an inch (eight millimetres) in diameter and cut similarly to a 
diamond ; so that instruments could gain no hold upon the 
facets. Extreme care should be exercised, in efforts to remove 
foreign bodies, not to injure either the canal or drum-head and 
ossicles. I have seen numerous instances in which unskillful 
practitioners had mutilated the canal-walls and drum-mem- 



■ 



DISEASES OF THE EXTERNAL AUDITORY CANAL. 61 

branes, and even extracted the little bones before they discovered 
that there really had been no foreign body in the ear. Such 
practices are appalling. It is frequently necessary to assure 
anxious parents that they and their children are mistaken, when 
they bring their little ones to have foreign bodies extracted, for 
we often find that there is absolutely no evidence that any 
foreign body has been there. 



CHAPTER VII. 
DISEASES OF THE MIDDLE EAR. 

Injuries of the Drum-head. 

The drum-head is occasionally ruptured by blows (Fig. 33) 
explosions, concussions from fire-arms, the pushing of pencils 
or straws into the ear, or by pulling the ears of children. The 
mere rupture of the membrane is not of serious import, for it 
will probably close in a few days without treatment ; but con- 
cussions or wounds may penetrate sufficiently to affect seriously 
the middle or internal ear. If no inflammation follow such 
accidents, the perforation itself requires no treatment further 




Fig. 33.— Rupture of the Anteroinferior Half of the Drum-head 
Caused by a Box on the Ear. (After Politzer.) 

than to protect it from the air-currents by a light pledget of 
sterilized cotton. The consequent affections are treated in their 
proper classifications. 



Inflammation of the Drum-head. 

Synonym. — Myringitis. 

Pathology. — Myringitis is of frequent occurrence and gen- 
erally begins with an injection of the malleal plexus of vessels. 
At first they can be distinctly seen like minute red threads 
running down along the hammer-handle, but as the hyperemia 
increases they appear to coalesce until there is an even diffusion 
of redness enveloping the handle and overspreading the mem- 
(62) 



DISEASES OF THE MIDDLE EAR. 



63 



brana flaccida like an intense blush. This condition may co- 
exist with a dermatitis of the superior integumentary wall of the 
external meatus. In these cases one cannot discern any line of 
demarkation between the lining of the wall and the drum- 
membrane. I remember to have seen an abscess in the drum- 
head of a violinist. It was seated in Prussak's space (Fig. 34). 
The hook-knife was introduced into the opening above and 
brought downward and outward, dividing the external wall, thus 
laying the little abscess-walls open to 
view. Occasionally hemorrhagic effu- 
sions are seen, but the blisters described 
by Politzer I have rarely observed. 
When the inflammation extends over 
the whole area of the membrane it 
assumes a cherry-red color, shining at 
first, and swollen and dusky after 
serous infiltration takes place. 

Etiology. — The cause usually lies 
in wind or cold water reaching the 
drum-head, swimming, instillations of 
irritating substances into the ear, fungi, 
or acute cold in the head. 

Symptomatology. — The hearing is 
not necessarily diminished for speech, 
but, on the other hand, there may be 
increased sensitiveness to noises. The 
pain is often severe and throbbing in 
character, accompanied with a feeling 

of fullness and pressure and subjective noises. Pain may be 
referred to the side of the head and neck, as well as to the 
ear itself. 

Diagnosis. — In the early stage this is not difficult, for the 
symptoms are not at all indicative of middle-ear inflammation 
except the appearance of the membrane. In mild cases the 
patient may not be aware of the presence of the trouble, 
although inspection reveals it, and the hearing is believed to be 
normal ; but in acute middle-ear inflammation the Eustachian 




Fig. 34. — Section Through 
the Tympanic Membrane, 
Malleus, and Upper and 
Outer Tympanic Wall of 
a Decalcified Prepara- 
tion. (After Politzer.) 

U, ligament, mall. sup. : le. 
ligament, mall, ext.: s. mem- 
brana Shrapnelli : o, Prussak's 
space : r, system of cavities be- 
tween the body of the malleus 
and incus and the external tym- 
panic wall : t, tendon of tbe muse, 
tens. tymp. 



64 DISEASES OF THE EAR, NOSE, AND THROAT. 

tube is usually involved, a rapid serous exudation takes place, 
and swelling of the membrane, with marked impairment of 
hearing. All the symptoms are characteristic of a more pro- 
found disturbance. After the inflammation extends from the 
drum-head to the middle ear the differential diagnosis is out of 
the question and immaterial. 

Prognosis. — This is favorable, the disease being generally 
limited to a few days or a week. 

Treatment. — If the pain is not severe the symptoms subside 
on warming pure vaselin and letting it run down upon the drum- 
membrane. Then the ear is closed with cotton to retain it 
for twenty-four hours. In severe pain a 10-per-cent. solution 
of cocaine, quite warm, gives relief used in the same manner. 
No other treatment is necessary except for complications or 
after-effects of the disease. 



Eustachian Tubal Catarrh. 






Pathology. — In Eustachian salpingitis the mucous mem- 
brane lining the tube may be simply hypersemic or highly 
inflamed. Since it is lined with a continuation of the same 
mucous lining of the naso-pharynx, on the one hand, and of the 
tympanic cavity, on the other (Fig. 35), any inflammatory action 
in one is likely to spread along the membrane to another part, 
just as an erysipelatous inflammation of the skin travels along 
the integument from one part of the body to another. In a 
transitory inflammation of the tube, mild in character, the mu- 
cous membrane alone may be affected, with only slight swell- 
ing and diminishing of its calibre ; but in a severer grade the 
submucous layer becomes involved, transudation of the fluid 
elements of the blood takes place, and great swelling and ste- 
nosis or complete closure of the tube occur. Asa result of the 
latter condition, new connective-tissue formation may make the 
narrowing or imperviousness of the tube permanent. Both the 
inflammation and the constriction are mostly confined to the 
cartilaginous part of the tube, and the connective-tissue strict- 
ures to the middle of this portion. Granulations sometimes 
result from the inflammation. 



DISEASES OF THE MIDDLE EAR. 



60 



Etiology. — Tubal catarrh is rarely an idiopathic disease, 
but results either from an attack of acute coryza, or pharyngitis, 
or from a middle-ear catarrh. Cold winds blowing on the side 
of the neck, a blow, or irritating fluids in the naso-pharynx may 
act as causes. The presence of hypertrophied oral or pharyn- 
geal tonsils, or of adenoid vegetations in the vault of the phar- 







g h t a 

Fig. 35.— Eustachian Tube and Tympanic Cavity 



(After Pulitzer.) 



a, membrana tympani ; b, head of the malleus ; c, lower end of the handle of the 
malleus ; d, body 6f the incus : e, short process of the incus : /. tensor tympani ; g, 
orifice of the Eustachian tube : h, isthmus of the tube : i, tympanic mouth of the tube. 

ynx, which are the seat of frequently-recurring attacks of 
inflammation, predisposes to the disease. 

Symptomatology. — In light attacks there are only slight 
deafness and subjective noises, which increase with the severity 
of the inflammation. When the tube becomes greatly swollen 
there may be vertigo, and pain referred to the side of the neck, 
back of the ramus of the lower jaw. Pressure toward the 
course of the tube reveals tenderness. Auscultation gives a 

b 



66 DISEASES OF THE EAR, NOSE, AND THROAT. 

high-pitched, squeaking noise during politzerization, and, if 
mucus is present, a rale also in a swollen condition of the tube. 
These are not necessarily present in the constriction due to con- 
nective-tissue growth. In the latter the noise may be want- 
ing. It is difficult or impossible to inflate the ear, or it will 
require high pressure to do so. The drum-head is sunken on 
account of the rapid absorption of air in the tympanic cavity 
and loss of the normal ventilation by the tube. The lower 
extremity of the mallet may lie in contact with the inner wall 
of the cavity, giving the hammer-handle a foreshortened appear- 
ance, and causing the short process to project outward promi- 
nently toward the eye. The membrane about this process looks 
stretched and drawn into folds. 

Diagnosis. — This is not difficult and the principal points 
have been indicated in what has already been said. With no 
middle-ear involvement, the most striking result is obtained 
from inflation. The hearing is immediately restored and the 
differential diagnosis confirmed. 

Prognosis. — The attack of acute catarrh of the tube is 
readily subdued, and proper treatment will soon restore the 
parts to a normal condition. 

Treatment. — This must be directed to the condition of the 
tube itself, to the causes that induce the attacks, and to the pre- 
disposing causes. The most immediate relief is afforded the 
patient if we can at once inflate the middle ear. This restores 
the normal hearing, relieves the tension on the drum-membrane, 
reduces the engorgement of the blood-vessels by relieving the 
partial vacuum ; removes the cause of dizziness, the impaction 
of the stirrup ; and lifts the patient out of his mental gloom, — 
a condition characteristic of this disease. The catheter should 
be avoided, since its introduction into the orifice of the inflamed 
tube serves only to increase the irritation. Politzerization is, by 
far, preferable, at first with air alone, to gently and gradually fill 
the tympanic cavity and restore the drum-head to its normal 
position. Too sudden inflation in this state may cause distress, 
vertigo, and nausea by the disturbance of the intra-labyrinthal 
fluid. The tube being opened, it is my practice to inject with 



DISEASES OF THE MIDDLE EAR. 67 

the improved inflator (Fig. 24) either pure lavolin — a purified 
non-irritating fluid vaselin — or a weak solution of camphor- 
menthol in vaselin, 3 per cent. The former is bland and emoll- 
ient, as well as protective to the inflamed membrane. The 
latter relieves the pain, constricts the capillary blood-vessels, 
reduces the swelling and stenosis, and acts as an antiseptic and 
protective. If the tube does not readily yield to the inflation, 
6 or 10 drops of sulphuric ether may be placed on the sponges 
of the inflator, and, with sufficient pressure from the compressed- 
air reservoir and while the patient swallows, this will, in most 
cases, reach the middle ear. There is not sufficient ether to 
produce irritation, but it is so volatile that it will penetrate 
where air alone fails to go. 

My experience differs somewhat from that of other ob- 
servers concerning tubal affections. I have rarely met cases of 
constriction that I was not able to overcome without the use 
of the bougie. This may be attributed, perhaps, to the greater 
air-pressure employed in my work. Moreover, it is rarely found 
necessary to introduce the catheter, — for the same reason, no 
doubt. Hand-bags are little used in my private practice or 
in my three hospital and college clinics, but, instead, we make 
use of air in reservoirs compressed by hydraulic compound 
pumps, Westinghouse air-pumps, or some other device supply- 
ing at least three or four times the amount of force obtainable 
from the rubber air-bags. But the amount of pressure is regu- 
lated by valves and air-meters so as to place it under the control 
of the operator and render it safe. 

Bougies have their disadvantages. They may abrade or 
lacerate the membrane of the tube and penetrate its weakened 
walls, or they may be carried onward into the tympanic cavity 
and dislocate the ossicles or perforate the membrana tympani. 
Air and emollient or stimulating medicaments are devoid of these 
dangers. Generally but a few treatments are required to open 
the tube and maintain its patency. I remember but one case 
in which it required as long as three weeks of treatment without 
the bougie to effect this result. That was in a chronic catarrhal 
condition with connective-tissue stricture, but the result was 



68 DISEASES OE THE EAR, NOSE, AND THROAT. 



satisfactory. The second indication for treatment is the reduc 
tion of the naso-pharyngeal or tympanic catarrh that may have 
given rise to the tubal trouble. But, since these conditions and 
the predisposing causes are treated of in their proper places, 
we will not repeat here. 

Acute Inflammation of the Middle Ear. 

Synonym, — Otitis media acuta. 

Pathology. — Otitis media acuta presents at first a glow of 
redness of the lining mucous membrane of the middle ear, due 
to the beginning hyperemia. This is perceptible through the 
translucent drum-head, and is followed rapidly by an effusion 
of serum and mucus into the tympanic cavity. These stages 
of inflammation follow each other in quick succession, and the 
disease itself is of short duration. The mucous membrane 
becomes tumefied and the epithelium becomes opaque and 
exfoliated. In a certain form of acute inflammation which is 
especially characteristic of the epidemic influenza, or, as it is 
generally known, the grip, there is so sudden an exudation as to 
cause rupture of the blood-vessels, and within twelve or twenty- 
four hours of the onset there is a copious, bloody, serous effu- 
sion and rupture of the membrana tympani. I have observed 
an influx of this type of the disease within a few days of the 
breaking out of the epidemic influenza in Chicago. 

Etiology. — This affection most often results from a cold in 
the head, and may be caused by an inflammation of any portion 
of the upper respiratory tract and by the eruptive fevers. Cold 
winds blowing j n the ear, getting wet, bathing, influenza, cauter- 
izing the nose and throat, pouring or sniffing cold fluids into 
the nose, and the entrance of soap and water into the meatus 
are prolific causes. It is more common to childhood than 
adult life. 

Symptomatology. — Sensations of itching in the ear some- 
times call the patient's attention to it before the actual pain 
begins, but the pains in other instances come on suddenly and 
without warning, and rapidly increase in intensity until they 
become unbearable. Especially is this the case in children, who 






DISEASES OF THE MIDDLE EAR. 



69 



are thrown into a fever, delirium, and even convulsions, so 
exquisite is the suffering. The pain is increased by sneezing, 
swallowing, and coughing, and it may radiate to the side of the 
head and teeth, or there is a sensation of numbness in the cor- 
responding side of the head. Autophony, or a peculiar sound 
of the patient's voice as perceived by himself, adds to his dis- 
comfort. If great pressure is exerted by an abundance of 
exudation, giddiness is experienced. Undoubtedly the labyrinth 
often participates in the disturbance to the extent of becoming 
hyperaemic, in which case subjective sounds become intense and 
even rhythmic, varying synchronously with the heart's pulsa- 
tions. It is not unusual to meet witli a mild type of this 
disease in which all the symptoms are diminished in intensity 
and some are absent. Hearing before the exudation may show 



«%■ 




Fig. 36.— Radiate Vascular Injection of the Drum-head. (Aft^r Politzer.) 



no impairment, but afterward it decreases proportionately to 
the amount of tumefaction and secretion. Bone-conduction is 
normal. 

Inspection reveals, in the beginning of the attack, a drum- 
head presenting the appearance described under the caption of 
" Myringitis " (Fig. 36). The malleal plexus of vessels is injected 
with blood ; their tracery along the upper region of the ham- 
mer-handle is distinctly made out ; a red areola shows about the 
processus brevis, and later a glow of redness covers the mem- 
brana flaccida. As the inflammation progresses the red appear- 
ance extends to every part of the membrane until it looks like 
a cherry in the ear. Later, as the serous infiltration increases, 
the outlines of the handle become dimmed and disappear ; the 
lustre of the membrane is lost, and in its place a dull, swollen 



"70 DISEASES OF THE EAR, NOSE, AND THROAT. 

surface presents. When the tympanic cavity becomes filled 
with secretions, inequalities of the surface of the membrane are 
visible, and a bulging in some part may indicate the pressure 
of fluid from within. Indeed, the whole membrane may become 
bulged outward, and the radiate traceries of the injected vessels 
show like the spokes of a wheel (Fig. 37). 

As the inflammation subsides the redness of the drum-head 
fades away, the pain ceases, the hearing improves, the noises 
diminish, and a general sense of relief takes the place of a 
stormy experience. The membrana tympani assumes a lustre- 
less, ashy-gray color, and its opacity remains for a considerable 
time, and may become permanent. 

Diagnosis. — There is little likelihood of confounding this 
disease with any other save myringitis alone. The latter forms 




Fig. 37.— Radiate Vascular Appearance in acute Inflammation of the 
Middle Ear. (After Politzer.) 

a factor in the present case and can, without much confusion, 
be separated from it. In the inflammation involving the whole 
of the cavity all the symptoms of inflammation of the drum- 
head alone are augmented, while others are ingrafted upon it. 
The great impairment of hearing after effusion, the general 
symptoms, and their duration are decisive. Children work at 
the affected ear, press it against warm objects, or incline the 
head to the diseased side. 

Prognosis. — The tendency is to resolution in healthy 
patients under favoring circumstances. In the opposite con- 
dition the tendency is either to suppuration and perforation of 
the drum-head or to a chronic catarrhal state. 

Treatment. — In the first stage, or before the serous effusion 
has taken place or the pain become severe, gentle inflation and 



DISEASES OF THE MIDDLE EAK. 71 

filling the ear-canal with warmed pure vaselin will suffice to 
give relief. When the pain has become intense, inflation 
must be made under very low pressure, as the movements of 
the drum-head, like those of an inflamed joint, are exquisitely 
painful. The patient in this stage should be put to bed to 
keep the temperature equable, a warm 10- or 20-per-cent. solu- 
tion of cocaine may be instilled into the ear, and, if deemed 
necessary, i grain of morphia can be given in combination with 
4^0" g ram °f atropia for an adult. If for any reason the 
morphia and atropia should not be prescribed, bromidia may be 
substituted in teaspoonful doses, in water, every half-hour until 
relief is obtained. Then it should be discontinued. The 
bowels and general health should receive proper attention. I 
have often found that leeches gave speedy relief. Two Spanish 
leeches may be applied in front of the tragus and two behind 
the auricle for adults. The external canal is stoppered with 
cotton so that the leeches cannot enter it. The skin is pricked 
until a drop of blood appears ; then the leech in a two-drachm 
vial, with its mouth at the opening of the bottle, is placed so 
that its mouth covers the drop of blood. The vial is held in 
position until the leech takes secure hold. Then the bottle is 
removed and the leech allowed to fill and drop off. This man- 
ner of applying leeches is given because few seem to be conver- 
sant with the subject, and this method removes the common 
objection to handling such repulsive animals. Especial care 
should be exercised to abstract the blood in middle-ear inflam- 
mation as much as possible from the region of the tragus, on 
account of the intimate relation of the blood-vessels of this 
region and the anterior wall of the meatus with the vessels of 
the tympanic cavity. If enough blood has not been abstracted 
after the leeches fill and fall off, more can be had by applying 
napkins wrung out of warm water. If there should be any 
difficulty in stopping the bleeding of the leech-bites, pressure 
applied to them will succeed. The artificial leech is also an 
excellent device, but occasions more discomfort. 

The practice indulged in by the laity of pouring oils, onion- 
juice, etc., into thp ear is a vicious one, since these become 



V2 DISEASES OF THE EAR, NOSE, AND THROAT 

rancid and irritating and predispose to a subsequent inflam- 
mation. Poultices are also mischievous and favor suppuration, 
and perforation of the drum-membrane. I have seen the follow- 
ing simple device, always convenient, give grateful relief: A piece 
of cotton is placed lightly in the mouth of the canal. A pipe 
is partly filled with tobacco and lighted. Then a piece of clean 
cloth is placed over the mouth of the pipe-bowl and gently 
blown through, while the lip-piece of the pipe-stem rests against 
the cotton pledget. This filters the warm smoke through the 
cotton into the canal, and a grateful sedative effect is soon ob- 
tained. I do not remember to have seen this remedy mentioned 
in the books, but I have witnessed its efficacy in the absence of 
other remedies. 

Fever calls for antipyrin or its equivalent in some febri- 
fuge that is less of a cardiac depressant. Phenacetin and ace- 
tanilid act well. Quinine, the enemy of the ear, must not be 
used. It aggravates the existing hyperemia and conduces to 
permanent deafness. Alcoholic drinks and smoking are pro- 
hibited, and any inflammatory condition of the respiratory tract 
must be vigorously combated. 

If the pain and bulging of the drum-head continue, not- 
withstanding all efforts to counteract the disease, and rupture 
of the membrane should threaten, it should be incised with the 
paracentesis-knife (Fig. 53, No. 2), in the postero-inferior quad- 
rant, so as to afford the most perfect drainage. A warm, 20- 
per-cent. solution of cocaine should be left in the ear for twenty 
minutes before the paracentesis, and, if the pain does not soon 
cease after perforating, more cocaine should be instilled, as hot 
as can be comfortably borne, so as to percolate through the 
perforation and reach the mucous membrane within. This will 
give freedom from suffering. The incision should be a long- 
one, cutting through the entire area of the postero-inferior 
quadrant vertically. The longer it is, the more it relieves the 
tension on the nerves of the membrane and the freer the drain- 
age. The paracentesis-knife must be absolutely sharp and 
dipped in alcohol before using. The perforation generally heals 
in a few days if no pus has formed. If we find suppuration has 






DISEASES OF THE MIDDLE EAR. 73 



taken place, then we have a condition which is considered in 
the following chapter. 

After the pain is relieved, which should be the object of 
our first efforts, the ear may be inflated with as low pressure as 
will accomplish it. The air-pressure in the tympanic cavity 
promotes absorption of any fluid contents and will likely im- 
prove the hearing. This treatment is administered daily for a 
few days. As improvement progresses the treatments can be 
given at greater intervals until the normal condition is 
established. 

Diet, exercise, and clothing should be regulated on general 
hygienic principles. 






CHAPTER VIII. 
DISEASES OF THE MIDDLE EAR, CONTINUED. 

Acute Suppurative Inflammation of the Middle Ear. 

Synonym. — Otitis media acuta suppurativa. 

Pathology. — The tissue changes already set forth in the 
description of acute inflammation of the middle ear take place in 
the affection now under consideration previously to pus forma- 
tion. In the suppurative form the inflammatory action is more 
intense ; the tissues break down ; the drum-head bulges with 
the pressure of the accumulated fluids (Fig. 38), becomes 
softened, and, yielding to the consequent pressure, ruptures. 
The whole tympanic cavity becomes involved, and the purulent 




Fig. 3S.— Convexity of the Drum-head Due to Pressure from Within. 

(After Politzer.) 

discharge may find its way into the mastoid antrum and cells. 
This disease is practically a sequel of the one described in the 
foregoing chapter. 

Etiology. — The causes of acute inflammation of the 
tympanum and those that give rise to suppuration are identical, 
and to avoid unnecessary repetition the reader is referred to the 
preceding chapter. But, in the case of suppuration, there is 
probably an invasion of the middle ear by micro-organisms 
through the Eustachian tube. Bezold found the diplococcus 
pneumoniae in suppuration of the middle ear in pneumonia. 
Streptococci or pneumococci are usually found in acute suppu- 
ration, followed by the staphylococci pyogenes. 
(74) 



DISEASES OF THE MIDDLE EAR. 75 

Symptomatology. — The symptoms here are a repetition of 
those already described in treating of acute inflammation up to 
the point of pus production, but in a certain proportion of 
cases the acute inflammation runs its course without the train 
of distressing symptoms there described. It often happens, 
especially in children, that the first intimation the parents have 
of any ailment is the appearance of a discharge from the little 
one's ear. On the other hand, some children are so violently 
affected as to suggest meningeal or brain disease. In such 
attacks as simulate intra-cranial affection the physician should 
never fail to examine the ears. 

Diagnosis. — Before perforation takes place it may be im- 
possible to differentiate between a simple acute inflammation 
with serous exudation into the tympanic cavity and a suppura- 
tive inflammation. As soon as rupture of the membrane occurs 
and the muco-purulent fluid is discharged into the meatus the 
diagnosis is cleared up. The appearance of the perforation, 
which can generally be seen after removing the discharge, and 
the presence of the latter not being due to an inflammation of 
the meatus, together with the whistling sound resulting from 
forcing the air through the perforation during politzerization, 
present the factors of a positive diagnosis. 

Prognosis. — If the habits of the body are bad, — tubercular, 
syphilitic, etc., — or if the suppuration result from diphtheria or 
scarlet fever, the prognosis is unfavorable ; otherwise, when all 
the symptoms are ameliorated soon after the discharge appears, 
the outlook is favorable. There is reason for apprehension if 
the severity of the symptoms continue unabated after an exit 
for the secretions has been provided either by nature or the 
surgeon. I have many times observed that when the inflamed 
parts showed pulsation and were very sensitive to the gentlest 
touch of the cotton-fluff, etc., suppuration was difficult to cure. 
The pulsation, which is synchronous with the heart-beats, can 
be seen distinctly if bright light is caused to be reflected from a 
moist spot on the drum-head. The pulse can easily be counted 
in this manner. Bulging of either the posterior or superior wall 
of the meatus, or symptoms referable to the mastoid process, 



76 DISEASES OF THE EAR, NOSE, AND THROAT. 

burrowing of pus, periostitis, or osteitis are indicative of serious 
complications. 

Treatment. — In the preceding chapter, in treating of acute 
inflammation of the middle ear, are given in detail the methods 
that should be adopted in acute inflammation up to the time of 
suppuration and rupture or paracentesis of the membrana tym- 
pani. to which the reader is referred. Taking up the subject 
then, at the point where rupture has occurred by the efforts of 
nature to cast off noxious material and relieve pressure, the 
first observation to be made is relative to the capacity of the 
perforation to meet the necessity for free drainage. If the fluids 
are copious and the opening is too minute to admit of sufficient 
freedom of exit to the discharge, especially if the pain be con- 
tinuous, the perforation should be enlarged vertically, as has 
been already described in the treatment of otitis media acuta. 
The tympanum must also be rendered freely accessible to the 
surgeon for the purposes of cleansing, disinfecting, and medi- 
cating the inflamed membrane within. 

Assuming now a free perforation, the external canal is 
dried out very gently with a fluffy cotton-twist projecting a 
quarter of an inch beyond the end of a small soft-silver cotton- 
carrier (Fig. 9). The cotton is rolled over the point of the 
carrier firmly enough to prevent it from penetrating the cotton 
and wounding the tissues, but beyond the twisted portion the 
cotton should be left in a downy tuft to absorb rapidly the fluids 
and to avoid any abrasion of the membrane. The cotton can 
be carried down into the fundus of the canal and brought in 
contact with the drum-head until all the secretions are absorbed 
and extracted. As the last of these are dried up, the fluid from 
within the cavity may be seen oozing out, a drop at a time, or 
rolling down from a nipple-like perforation (Fig. 39). If one 
is not expert in the manipulation of these instruments, it is 
better to cleanse the canal by syringing it with a quart of water 
as warm as can be comfortably borne, the water having been 
sterilized by boiling for ten minutes. 

After freeing the meatus of all discharges the ear is care- 
fully inflated with as low pressure as will propel a column of 



DISEASES OF THE MIDDLE EAR. 



77 



air outward through the perforation. The discharges are hy 
this means projected through the perforation into the canal with 
a whistling or bubbling sound. If too great force is exerted, 
unnecessary pain is caused. Any fluids ejected into the meatus 
are then removed ; the canal is well dried and insufflated with 
aristol from the small powder-blower (Fig. 32). This remedy 
is preferable to boric acid in that it possesses a feeble anaesthetic 
property. It is the best cicatrizant we have, and, being the 
finest kind of a powder, it can be dusted through a narrow per- 
foration. A small pledget of absorbent cotton is then introduced 
lightly into the mouth of the meatus and allowed to remain 
until further discharge appears. Patients are instructed to let 
their ears entirely alone in case they remain dry after treatment, 
but if the cotton becomes moist with the discharge they are to 




Fig. 39.— Nipple-shaped Bulging of the Posterior Portion of the Drux- 

HEAD, ON THE SUMMIT OF WHICH IS THE PERFORATION. (After Politzei.) 

syringe the ear (Fig. 31) as previously described, and instill a 
warm, saturated solution of boric acid in water or rose-water, 
allow it to remain ten minutes, then let it escape, and close the 
ear lightly again with clean cotton. 

The cotton stopper protects the sensitive drum from cold 
winds or drafts and absorbs moisture. This constitutes an ideal 
dry dressing, and in suppuration of the ear, as of other organs, 
the drier the treatment, the better the results. The ear already 
presents the most favorable condition for the development and 
propagation of bacteria, — warmth and moisture. This con- 
dition we must combat ; so that, whatever our treatment may 
consist in, the aim should be to leave the parts as dry as 
possible. For this reason boric acid is an excellent dressing, 
especially when all acute symptoms have subsided. However, 



78 DISEASES OF THE EAR, NOSE, AND THROAT. 

during the acute stage boric acid may cause pain for several 
hours after its application. I have met with quite a number 
of such instances in which it became necessary to discontinue 
the use of this powder. I have suspected that certain indi- 
viduals possess an idiosyncrasy against it, but, if it produce 
no discomfort, excellent results may be expected. It absorbs 
moisture and dries the tissues. If fluids come in contact with 
it a saturated solution of boric acid is formed, which may per- 
colate through the perforation into the middle ear and there 
exercise its feebly germicidal power. No powder, however, 
should be firmly packed into the ear, for it would prevent the 
escape of discharges and cause them to seek an outlet else- 
where : through the Eustachian tube if it were fortunately 
pervious, or through the mastoid antrum and cells, or even by 
way of the internal meatus or the tympanic roof to the cranial 
cavity. Moreover, it should never be forgotten how intimately 
the middle ear and mastoid spaces are related to the contents 
of the cranial cavity by the connecting blood-vessels, lym- 
phatics, and by occasional defects in the superior surface of the 
temporal bone. These conditions emphasize the necessity of 
always keeping the passage-way for the flow outward unob- 
structed. 

In case the drum-membrane and the canal remain very 
sensitive and pain continues unabated in the ear, a 12-per-cent. 
solution of carbolic acid in glycerin generally gives relief. 
The acid anaesthetizes and disinfects without corroding the 
tissues when combined with glycerin, and the latter unloads 
the blood-vessels of their superabundant serum. The tumes- 
cence of the vessels is diminished and the pain relieved. Gen- 
eral treatment is to be resorted to when the conditions demand 
it. The body should be protected from sudden atmospheric 
changes by wearing wool next the skin. Further elucidation 
of tiiis subject will be found under the heading of "Treat- 
ment" of coryza. 

Since the disease under consideration is largely the result 
of acute catarrh of the nose and throat, coincident treatment 
should always be addressed to the naso-pharyngeal affection, 



DISEASES OF THE MIDDLE EAR. 



79 



and our efforts must be directed toward removing any perma- 
nent causes of recurring attacks, such as hypertrophies in the 
nasal chambers, adenoid growths in the pharynx, and enlarged 
tonsils. (See chapters on these subjects.) 

Chronic Non-suppurative Inflammation of the Middle Ear. 
Under this name are classed hypertrophic middle-ear catarrh 
and adhesive middle-ear catarrh, — sclerosis (see Chapter IX). 




Fig. 40.— Fluid Effusion in the Tympanic Cavity, Marked by a Bright 
Line. (After Politzer.) 

HYPERTROPHIC, OR SECRETIVE, CATARRH OF THE MIDDLE EAR. 

Pathology. — Hypertrophic, or secretive, catarrh of the mid- 
dle ear occurs in association with a similar condition of the nose 
and naso-pharynx. There is an hypereemic condition of the mu- 
cous membrane lining the tympanic cavity, with hypersecretion 




Fig. 41.— Circumscribed Bulging of the Drum-head, Due to Pressure of 
Fluid in the Middle Ear. (After Politzer.) 

of a serous or mucous character. The exudation may be visible 
(Figs. 40 and 41) if the drum-head has not lost its translucency, 
more especially when air has been forced through the Eusta- 
chian tube into the fluid, thereby causing bubbles or a frothy 
appearance. In this disease the tube generally participates to 
the extent of losing its patency; so that the normal supply of 



80 



DISEASES OF THE EAK, NOSE, AND THROAT. 



air in the middle ear is cut off. The result is that the air 
in the middle ear is absorhed ; so that the resistance of the 
drum-head to the outward atmospheric pressure of nearly fif- 
teen pounds to the square inch is lost, and the membrane is 
forced inward toward the inner tympanic wall. The effect of 
this encroachment upon the tympanic space is easily visible in 
the increased concavity of the membrane, the foreshortening of 
the hammer-handle, the emphasizing of the posterior fold, and 
the changed location of the reflection of light. 

The drum-head yields to the atmospheric pressure from 
without when the counteracting air-pressure from within is lost, 
and lies, perhaps, in contact with the inner wall, especially the 
posterior half. In this case it may so embrace the long process 
of the anvil and the posterior cms of the" stirrup as to show 




Fig. 42— Ctkeat Concavity of the Drum-head and Foreshortening of the 

Hammer-handle. (After Pulitzer.) 

their projecting outlines and those of the promontory and round 
window. The mallet-handle may at first seem to be invisible 
until one looks from below upward as much as possible, when it is 
seen occupying an almost horizontal position (Fig. 42), running 
directly inward until its lower extremity lies in contact with the 
inner wall of the cavity. The short process is thrown outward 
by this position toward the examiner's eye like a little yellow 
knuckle covered with membrane that is stretched into tense folds 
above. If the drum-head is still lustrous the triangle of light 
has been moved from its normal position, or there is a circular 
reflection of light from the most depressed section, or there may 
be several dots of light, owing to the irregular surface produced 
by the varying degrees of depression in different parts of the 
membrane. In an advanced stage these irregularities of retrac- 



DISEASES OF THE MIDDLE EAR. 81 

tion are due to an atrophied condition of one or more parts of 
the membrane, and, unless a careful inspection is made, these 
atropines may be easily mistaken for cicatrices. The latter, how- 
ever, are more clearly defined by the distinct line forming a bor- 
der to a previous perforation and now separating the cicatricial 
tissue from the opaque, thickened membrane surrounding. 
The atrophic area blends gradually in more indefinite outlines 
with the adjoining hypertrophic tissue. 

The massage otoscope (Fig. 8) shows these atrophic and 
cicatricial sections with unmistakable clearness. When the air 
is rarefied in the canal, these spots bulge outward like balloons, 
as if they might burst. Indeed, they probably could be easily 
ruptured if much force were exerted. They show exaggerated 
movements when the remainder of the membrane and the 
mallet are completely quiescent. But, when the drum-head is 
depressed against the inner tympanic wall and has become ad- 
herent to it by organic adhesions, these adhesions prevent the 
depressed area from responding to the pneumatic otoscope. 

In the more advanced stage of this disease the drum-head 
becomes very greatly thickened and of a milky opacity, and 
hypersecretion and impaction of cerumen are frequently found. 

Etiology. — Acute colds in the head, influenza, the eruptive 
fevers, chronic naso-pharyngeal catarrh, and syphilis act as 
the exciting causes of this affection. Impermeability of the 
Eustachian tube, with consequent rarefaction of the air in the 
middle ear, causes an exudation of serous fluid, retraction of 
the drum-head, etc., which may only prove to be transitory 
if the cause of the tubal stenosis is speedily removed, or, if it 
is not, permanent tissue changes may occur, resulting in the 
more serious conditions described. 

Symptomatology . — This is not a painful affection, although 
in the early stages slight twinges or darting and shooting tran- 
sitory pains may occur. Sensations of fullness in the ear, press- 
ure, and as if something w 7 ere moving in the ear are complained 
of. The last symptom is produced by movements of the fluid 
contents of the tympanic cavity, ow 7 ing to the varying positions 
of the head and to the entrance of air into the fluid through 



82 DISEASES OF THE EAK, NOSE, AND THROAT. 

the tube. The last cause also gives rise to bubbling, snapping, 
and crackling sounds. These rales result from the separating 
of the walls of the Eustachian tube also, when it is involved, 
as air passes through. The viscous mucous secretion agglutin- 
ates the walls together, and as they separate the clinging mucus 
first sticks, then stretches into filaments, and the breaking of 
these occasions the crackling noises. The movements of the 
jaw aggravate these symptoms. Sensations of numbness in 
tlie corresponding side of the head, confusion of ideas and 
speech, irritability of temper, and autophony — or a disagreeable 
hollow sound of one's own voice, as if talking into an empty 
barrel — are characteristic of this disease. 

The swelling of the tissues and increased tension of the 
drum-head and ossicles may produce labyrinthal pressure with 
a sense of light-headedness, giddiness, and subjective noises, 
although the latter constitute one of the principal symptoms of 
sclerosis. The hearing varies greatly with the weather con- 
ditions. Low barometer and thermometer, with great humidity 
of the atmosphere, increase the impairment of hearing, the sen- 
sations of stuffiness and fullness, and tinnitus aurium. Sudden 
changes to these atmospheric conditions from a warm, dry air 
are certain to aggravate the aural symptoms. Patients can pre- 
dict approaching weather changes by the phenomena mentioned. 
Alcoholic stimulants and colds in the head also increase these 
distressing symptoms. 

Diagnosis. — It is not difficult to determine the presence of 
the secretive form of catarrh. If the drum-head is yet trans- 
parent the line in the membrane indicating the surface of the 
liquid can be made out unless it extends above into the attic, 
or the propelling of air into it can be heard to produce bubbling 
sounds, and in the early stages the hearing may not be greatly 
impaired or it is much improved by politzerization. The patient 
is generally young, bone-conduction for the watch and tuning- 
fork is good, and the disease is far more amenable to treatment 
than is sclerosis. 

Prognosis. — This is favorable if we can exclude heredity, 
bad sanitary influences, and general ill health, and if the attack 



DISEASES OF THE MIDDLE EAR. 83 

is not of long duration. Especially is this so if inflation of 
the ear and removal of any contained fluid result in decided 
improvement in the symptoms and if the bone-conduction is 
good. But examination of the nose and throat will throw im- 
portant light on this subject. If there are no hypertrophies 
and exostoses, but a simple catarrh of recent origin, a cure is 
readily effected. 

Treatment — Attention must first be directed to the pass- 
ages that lead to the middle ear. If there exist a catarrhal con- 
dition of the nose and throat that may have given rise to the 
middle-ear disease, it should receive proper treatment at the 
same time with the Eustachian tube and tympanum. Per- 
manent cure of the ear affection cannot be effected so long as 
the exciting cause of such attacks remains in the nasopharyn- 
geal tract. The Eustachian tube, if diseased, should be the 
subject of proper measures to render it permanently patulous 
and healthy. The air-douche by the Politzer air-bag or the 
compressed-air apparatus is sufficient in many recent cases to 
cause absorption of secretions in the middle ear and the reduc- 
tion of hyperaemia and swelling of the mucous membrane. By 
this means the natural ventilation by the canal is effected and 
the drum-head is restored to its normal position and tension. 
This inflation should be carried out daily until the improvement 
obtained at each sitting remains permanent until the next ; then 
the time is lengthened to two, three, or four days or more, or a 
week or two between the treatments, according to this rule, 
until the cure is complete. As soon as the organ is apparently 
restored to its normal condition treatment should be discon- 
tinued, as a retrograde may otherwise occur. Overtreatment is 
certainly to be avoided. At each sitting the inflations are re- 
peated from two to four or six times, with not enough pressure 
to cause pain or bright redness of the membrana flaccida. The 
vessels along the upper portion of the handle of the mallet 
often become injected even after gentle inflation. 

Massage by the pneumatic otoscope is practiced after the in- 
flation sufficiently to insure the normal mobility of the ossicles, 
but not to produce discomfort in the drum or any irritation. 



84 DISEASES OF THE EAR, NOSE, AND THROAT. 

For the removal of the fluid contents of the tympanic 
cavity that do not disappear after inflation, a number of years 
ago 1 devised a method that I have never seen mentioned ex- 
cept once, which was in a journal article that appeared about 
three years after my publication. The patient inclines his head 
forward and a little toward the opposite side, and practices an 
experiment that just reverses the Valsalvan method. He closes 
the nose with thumb and forefinger and draws the air from the 
naso-pharyngeal space down into his throat. This method 
exhausts the air of the cavities above the pharynx and sucks 
the secretions from the middle ear and Eustachian tube into the 
throat ; they can be seen immediately afterward trickling down 
the side of the pharynx from the region of the tube-orifice. 
When the drum-head was perforated I have utilized this same 
method to draw medicated solutions from the external meatus 
through the middle ear and tube into the pharynx or nose. 
This thoroughly washes these surfaces with the remedies used. 

The treatment outlined does not mention the catheter for 
the reason that, since the introduction of the modern improved 
instruments for treating the ear, nose, and throat with com- 
pressed air, the catheter is rarely a necessary instrument. It is 
— in my practice, at least — relegated to the company of instru- 
ments rarely honored by use. The reason of this is that the ■ 
improved inflator (Fig. 24) will inflate the middle ear in almost 
every instance in which it is properly employed. This saves 
the patient suffering, prevents injury to the inflamed walls of 
the tube, and avoids the possibility of infection, as the inflator 
is not carried into contact with the mucous surfaces as the 
catheter is. 

If my method of auto-aspiration of the tympanic cavity 
through the Eustachian tube should not suffice on account of 
the thick, tough character of the secretion, paracentesis should 
be made under antiseptic precautions as described in the treat- 
ment of acute inflammation of the middle ear. After opening 
the membrane air is thrown through the tube and tympanum 
so as to eject all discharges from them into the external meatus. 
There need be no fear that any permanent damage may be 



DISEASES OF THE MIDDLE EAR. 85 

done by the paracentesis, for it will undoubtedly close in a few 
days. The expelled secretions should be absorbed by cotton on 
a carrier and the canal left dry. The meatus is then closed 
with absorbent cotton. Should fluid accumulation recur the 
membrane may have to be re-opened, even repeatedly in excep- 
tional cases. A few days or weeks of this treatment generally 
suffice for a cure, but the more obstinate conditions require 
months for their eradication. 

The treatment for associated rhinitis and pharyngitis will 
be found under those headings. 

Medicinal applications may be advantageously employed 
when simple air-douches fail to reduce the tumefaction and 
hyperemia of the lining tympanic membrane. A number of 
years ago I introduced the use of purified liquid vaselin, and 
later camphor-menthol in lavolin, for treating tubal and tym- 
panic catarrh. The physiological action of camphor-menthol is 
given in Chapter XVIII. Sprays of these remedies are thrown 
into the tube and middle ear by means of the improved inflator. 
The sponges it contains are moistened with the liquid and, by 
applying the cut-ofT of the compressed-air tube to the inflator, 
a jet of the remedy- is projected into the tube and tympanum. 
I have learned that Charles Delstanche, of Brussels, preceded 
me in the use of liquid vaselin in the middle ear. This treat- 
ment is usually best followed by the massage otoscope. After 
the treatment has effected all that is possible I have observed 
that patients maintain their improvement and even continue to 
improve, after changing their residence from low and damp sur- 
roundings to a high, dry, and equable climate. 

Operations on the drum-head are treated of in Chapter X, 
and hygienic measures are considered in the treatment of acute 
rhinitis, or corvza. 



CHAPTER IX. 

DISEASES OF THE MIDDLE EAR, CONTINUED. 

Sclerosis, or Adhesive Inflammation, of the Middle Ear. 

The line of demarkation cannot be distinctly and unmis- 
takably drawn between the early adhesive and the late hyper- 
trophic form of middle-ear catarrh. The latter may merge 
by imperceptible degrees into the adhesive variety, and the 
sclerotic processes may pass through their initial stage during 
the activity of the hypertrophic inflammation. But the most 
intractable forms of deafness — involving ankylosis of the ossicles, 
especially immobility of the stapes, and labyrinthal involvement 
— characterize the adhesive, or sclerotic, catarrh. 

Pathology. — While this form of catarrh may affect the 
whole lining membrane of the middle ear, it may be circum- 
scribed and limited to the tissues surrounding the oval and 
round windows. A distinguishing characteristic is an insidious 
interstitial inflammation, induration, and chronic thickening of 
the tissues, or sclerosis. But in a considerable proportion of 
cases there is progressive atrophy; pale, thin membrane, and 
calcareous degeneration. Again, there may be an excessive 
proliferation of connective tissue, filling and even obliterating 
the cavity of the attic and of the oval and round fenestra and 
binding down the ossicles to such a degree as to impede or pre- 
vent their normal movements. Bands connecting the membrana 
tympani and ossicles together increase the normal tension of the 
conducting apparatus, resulting in varying degrees of deafness. 
These bands become the seat of calcareous degeneration, with 
the result of binding the ossicles to. each other, to the membrana 
tympani, and to the tympanic walls with rigid or bone-like 
bridges. The drum-head is often the seat of these chalky de- 
posits, which generally appear like miniature drifts of snow in 
crescentic forms below and about the mallet (Fig. 43). 

Ankylosis of the ossicles takes place either by increased 
(86) 



DISEASES OF THE MIDDLE EAR. 



87 



fibrous-tissue formation or by bony growth. Ankylosis is in- 
frequent between the anvil and stirrup, but is frequent between 
the mallet and anvil, and between the stirrup-plate and the 
border of the oval window. Indeed, we may have all these 




Fig. 43.— Semilunar Chalky Deposit in Front of the Handle of the 
Mallet. (After Politzer.) 

ankyloses combined with bands of adhesions binding the mem- 
brana tympani and ossicles together, and hypertrophy and 
calcareous degeneration of the membrane of the round window. 
The natural filaments and bridges of mucous membrane con- 
necting the crura of the stirrup with the oval foramen (Fig. 4-i) 
favor the fixation of this bone when fibrous or calcareous 



r, JS 




Fig. 44.— Niche of the Fenestra Ovalis, with the Crur.e of the Stapes, 
in the Normal Ear of an Adult. (After Politzer.) 

Net-work of bands extending from the neck of the stapes to the walls of the niche, 
c, head of the stapts ; s, s, crura? of the stapes. 



changes occur. Calcification or ossification may take place in 
the ligamentous ring of the stirrup, and bony union with the 
oval window may result, Calcareous deposits have been found 
in the malleo-incudal joint, and I have suspected that in patients 



88 DISEASES OF THE EAR, NOSE, AND THROAT. 

of a uric-acid diathesis there might occur deposits of urate of 
soda in these joints as well as in the other articulations. Kichey 
believes sclerosis to he closely related to progressive arthritis de- 
formans. In a conversation with Professor Politzer upon this 
subject, in 1893, I asked him if he had ever discovered such a 
deposit, but he replied that he had not, since, in his method of 
preparing specimens, any evidence of such deposits would be 
destroyed. 

The Eustachian tube may participate in a diffuse form of 
this inflammatory process and become stenosed, but it is often 
normally permeable and even abnormally patulous. 

Etiology. — The hypertrophic, or secretive, inflammation of 
the middle ear predisposes to the adhesive or dry sclerotic form. 
The latter is noticeably hereditary and can be often traced to 
the father and his family or to the mother and hers. The 
brothers or sisters are often more or less afflicted. General dis- 
eases that are destructive of tissues and exhausting to the gen- 
eral strength promote this form of middle-ear catarrh. Chronic 
catarrh of the nose and throat and excessive indulgence in 
alcohol and smoking bear a close causative relation to sclerosis. 
Yet I cannot place the emphasis on smoking that some authors 
do, since I have seen the worst examples of this disease in both 
women and men who were not at all addicted to the use of 
tobacco. 

The hypertrophic form might be spoken of as a disease 
of childhood, during which it is very common ; but sclerosis is 
a disease of middle and old age. In my experience it nearly 
always is seen in persons over 30 years of age, rarely in those 
younger, and mostly in those much older. It generally affects 
both ears, and, although patients often aver that only one ear is 
troublesome, the surgeon should never fail to examine both — 
and the naso-pharynx as well. 

Symptomatology. — Tinnitus aurium constitutes the most 
distressing symptom. Patients often declare that if the noises 
only can be conquered they will be satisfied, whether their hear- 
ing can be improved or not. These are variously described as 
high-pitched ringing, like that produced by quinine or by boxing 



DISEASES OF THE MIDDLE EAR. 89 

the ears; like roaring or rushing of waters ; crickets ; hissing ; the 
singing of a tea-kettle ; sighing of the winds, . etc. The in- 
tensity of the tinnitus is usually in proportion to the loss of 
hearing, until the miserable subject can hear little or nothing 
but the interminable storm of confusing and crazing noises, 
compared to which the clanging and crashing of the kettle- 
drums and cymbals in a Wagnerian overture are a heavenly 
melody. 

The suffering is increased by cold, wet, and windy weather ; 
taking cold, alcoholic drinks, speaking or reading aloud, and 
anything that produces excitement or depression of the strength 
or spirits. Sometimes a startling loud sound rings out suddenly, 
without any apparent cause, like a stroke from a hammer on a 
high-pitched bell ; then gradually it dies away until it is lost in 
the confusion of other less intense subjective sounds. Often 
patients declare that the noises are not in the ear itself, but 
refer them to the side of the head and even to the occiput. 
Most frequently, however, I have noticed that they place the 
tips of their fingers over the hearing- centre in the brain when 
locating the sounds outside of the ear. They sometimes believe 
it is possible for others to hear these noises if the observer's 
ear were to be placed close to their own. I have known some 
patients to insist that crickets or other animals were in their 
ears, and that I must remove them, when the symptoms were 
entirely subjective. 

On the other hand, persons of discipline of mind and 
strong will suppress mentally these besieging enemies to con- 
secutive thought and intelligent action until they are scarcely 
conscious of their presence while engaged in active occupations. 
But when the mind becomes disengaged for a time in a quiet 
place, or more especially when there is occasion for listening 
intently to a speaker, the noises seem to surge back into the 
presence of the conscious mind with furious intensity. Very 
nervous individuals are so overwhelmed by this symptom that 
they may succumb, and part with their reason. 

Severe or continuous pain is not a symptom of sclerosis, 
but sharp, stinging pains lasting but a few seconds or minutes 



90 DISEASES OF THE EAR, NOSE, AND THROAT. 

are not uncommon. Great sensitiveness to certain sounds and 
to concussions of the air exists. The slamming of a door may- 
he painful, owing to the noise or to the concussion or both. 
With increased tension of the conducting apparatus and impac- 
tion of the foot-plate of the stirrup in the oval window, there is 
an increase of labyrinthal pressure and more or less vertigo and 
sense of tightness or pressure in the head, although the patient 
may not be able to particularize or localize it unless he possesses 
a very observant mind. 

The hearing is generally much worse in sclerosis than in 
hypertrophic catarrh, and shows less variation either with or 
without treatment. The hearing may vary during the day. 
One individual hears better in the morning and worse in the 
evening. Another hears better until 4 o'clock in the afternoon, 
when the hearing becomes dull, to remain so the rest of the 
evening. Another hears worse in the morning until he has his 
breakfast and boards the train for the city, when the jar of the 
car appears to produce a commotion in his ears, his Eustachian 
tubes open to the admission of air to the tympanic cavities, and 
at once he hears better and experiences a sense of clearness and 
relief in his ears. In the noise lie hears better, even better than 
those with normal hearing. A locomotive engineer under my 
care said he could hear better than his companions w 7 hen his 
engine was in motion, and that his employers, for whom he had 
worked several years, did not suspect his hearing impairment. 
He managed to give them no opportunity of conversing with 
him except in a noise. The vibrations of his engine communi- 
cated motion to his conducting apparatus, which then conveyed 
sound-waves that were too feeble of themselves to institute these 
movements. 

Another interesting fact has come under my observation. 
A long-standing catarrh of one ear had so impaired its useful- 
ness that the patient did not consciously depend upon it. The 
better ear had lost its usefulness through an attack of epidemic 
influenza, when the patient was obliged again to depend on the 
previously worse ear. Then it was found that, although sounds 
could be distinguished in it, they could not be understood. 



DISEASES OF THE MIDDLE EAR. 91 

Words could be heard, but not interpreted, on account of long 
disuse of the organ. It became necessary to practice with the 
various words in common use until they could be distinguished 
from each other and correctly interpreted. The process was com- 
parable to learning a new language, but it was accomplished. 

In this case the sounds of the C and C, 128 and 256 
vibrations, are perceived by air and bone at the correct pitch by 
both ears. The C" and C"' \ 512 and 1024 vibrations are always 
heard at the proper pitch in the right ear, and by bone in the 
left ear ; but by air in the left they are perceived as a half-tone 
above the real pitch. Fork C"", 2048 vibrations, is lieard in 
both ears faintly, when almost touching the mouth of the 
meatus, but not by bone with either ear. The patient dis- 
tinguishes with difficulty between this fork and the subjective 
ringing, which is of the same pitch. 

The hearing for speech is the most affected, while hearing 
for music, etc., may remain fair. The musical composer, 
Emerson, was afflicted with greatly impaired hearing for speech ; 
but he mastered the trying requirements of a great musical 
conductor. Hearing better in a noise, paracusis, is character- 
istic of this form of ear disease. By the simple expedient of 
causing sound- vibrations in the air by means of such a device as 
an electric hammer, or the electric bell with the gong removed, 
or a spring and ratchet in an electric fan, one with this form of 
deafness will be able to conduct business communications when 
otherwise he could not without a conversation-tube or horn. 
It is not, however, the commotion of the air produced by the 
fan-wings that aids hearing, but the sound-waves that keep the 
drum-membrane and ossicles in vibration. 

Bone-conduction is not so likely to be normal in this as in 
the hypertrophic process. It is often much diminished or alto- 
gether absent. But it should not be forgotten that bone-con- 
duction begins to show reduction after the thirtieth year. The 
hearing for the highest tones and the very low notes is di- 
minished or lost in the order named. Certain notes in the 
medium register may also be unperceived, which indicates 
labyrinthal implication. 



92 



DISEASES OF THE EAR, NOSE, AND THROAT. 



Diagnosis. — The appearances of the drum-head vary 
greatly. There are thickening and retraction of the membrane 
(Figs. 45 and 46) with foreshortening of the mallet-handle in 




Fig. 45.— Maukkd Rktkaction of the Drum-head. (Alter Politzer.) 

some cases (Fig. 42), while in others there is atrophy with 
chalky deposits or, in yet other cases, a membrane of quite 
normal appearance. The adhesive process may be confined to 




Fig. 46.— Circumscribed Depressions in the Anteroinferior Quadrant 
of the Left J)rum-head. (After Politzer.) 

circumscribed areas on the surface of the inner wall which in- 
spection does not reveal. The Eustachian tubes may have been 
involved during the early stages, while later in the history of 



^m 




Fir;. 47.— CIRCUM8CRIBED ADIIKSION OF THE AlEMBRANA TyMPANI TO THE PRO- 

hontoky I'ndkrnkath the Handle of the Mallbt. (After Politzer.) 
a, point of adhesion. 

the case they may be freely permeable. The massage otoscope 
will show any adhesion of the membrane to the inner wall (Fig. 
47) and the amount of mobility that the mallet may have lost. 



DISEASES OF THE MIDDLE EAR. 93 

It will also reveal bands of adhesion that may exist super- 
ficially behind the membrane if the latter is pressed by the air 
inward so as to lie against and embrace these bands. When 
there is normal freedom of motion of the hammer during the 
massage, it is certain that its articulation with the anvil and the 
articulation of the latter with the stirrup cannot be ankylosed ; 
but the stirrup may be ankylosed in the oval foramen. In such 
cases with a normal-looking drum-head one must be very 
guarded in his prognosis, for they are sometimes intractable and 
hopeless. 

Prognosis. — From what has been said it will be naturally 
inferred that brilliant results may not be expected from treat- 
ment in a large proportion of cases of sclerosis of the middle 
ear. The outlook will be more favorable if the disease is not 
of long standing, if tinnitus is either absent or only an oc- 
casional symptom, if the hearing is not seriously impaired, if 
bone-conduction is normal, and if treatment produce a decided 
amelioration of the symptoms. The reverse of these circum- 
stances renders the prognosis unfavorable. Age, general health, 
sanitary surroundings, personal habits, heredity, and occupation 
must also enter into the account. 

Treatment. — We can hardly speak of treatment in this 
form of middle-ear catarrh as curative. We must candidly 
admit that in otology, as well as in other branches of medicine, 
there are maladies that baffle the most skillful practice of our 
art. All that we can hope to accomplish is to stay the progress 
of a persistent process. A patient under my treatment at the 
present time said, when informed that he had lupus: "Then I 
will have nothing done." I replied : " If a wolf were biting 
you, would you not want me to take him oft"? " So in the case 
of sclerosis ; it is our duty to interpose every possible obstacle 
to the development and progress of the pathological process that 
is attended with such distressing and deplorable results. If no 
more can be accomplished than to relieve the never-ending din 
of harassing noises that incessantly bombard the brain, it is 
worth the while. This confusing strife of discordant sounds, 
this concentration of all the overtones in nature focused on a 



i)4 DISEASES OF THE EAR, NOSE, AND THROAT. 

sensitive being almost deprived of normal, intelligible, sweet- 
toned sounds, too often test the tension of the mind to the 
breaking-point. 

The most common and simple treatment is the injection of 
air; but, in order to accomplish enough movement in the mem- 
brane and ossicles to stretch or break bands of adhesions and 
to overcome ankylosis, more force must be applied than is 
recommended in the simple hypertrophic catarrh. While the 
latter may require with a patulous tube no more than an atmos- 
phere, or 15 pounds, or less, I have employed 60 and even 80 
pounds without producing much impression on these old, 
hardened, thickened, leathery drum-heads. This is not men- 
tioned as an intimation to the unpracticed that they should use 
so much pressure, but 30 pounds' pressure is often required to 
produce any motion in the ossicles. Wiirdemann advocates 
similar treatment, with the air-regulator. When the foot-plate 
of the stirrup is not ankylosed, some transitory giddiness may 
be occasioned by this pressure, but in case it is immovable we 
cannot look for dizziness to occur from inflation. If we can 
obtain sufficient movement in the stirrup to produce momentary 
vertigo it brightens the outlook, for it indicates that bony union 
has not yet taken place between the base of the stirrup and the 
border of the oval foramen. If inflation and massage are fol- 
lowed by an amelioration of the symptoms, improved hearing, 
abatement of the tinnitus, relief of sense of pressure, and a 
feeling of clearness in the head, then the prospect is encourag- 
ing. If a few weeks of daily treatment should make no per- 
ceptible impression of any kind, the opposite is true. But the 
massage treatment on alternate days is a most important auxil- 
iary to politzerization, and we can now profitably enter into its 
detail. 

The author's massage otoscope (Fig. 8) possesses some 
advantages over others. As compared with Siegle's pneumatic 
speculum, the author's otoscope is (1) self-illuminating, not 
requiring the aid of a hand-mirror or forehead -mirror, the light 
being accurately focused on the drum ; (2) it affords a mag- 
nified view of the drum ; (3) it can be operated in a smaller 






DISEASES OF THE MIDDLE EAR. 95 



canal than will admit the speculum ; (4) the bright reflection 
of light into one's eye by the glass of the speculum, the black 
background of which converts the glass into a mirror, is avoided 
in the otoscope by the proper and unvarying relations and the 
color of its various parts. The directions for manipulating this 
instrument are given in Chapter II. 

By alternately rarefying and condensing the air in the 
meatus the amount of mobility in the drum-head and the chain 
of bones may be determined under brilliant illumination and 
magnified inspection. If ankylosis of the joints of the ossicles 
or if bands of adhesions between the bones and the walls of the 
tympanum exist, the handle of the malleus will be seen to be 
impeded in its movements, or it may remain fixed, while the 
membrane about it may be quite flaccid, and respond to the 
rarefaction of air by bulging outward about the mallet-handle 
(Fig. 38). If the membrane is greatly thickened in patches or 
if it contain calcareous deposits, these portions will be seen to 
resist the action of the vibrating column of air, while normal 
parts and areas of thin, cicatricial tissue that indicate the loca- 
tion of former perforations may respond readily to the experi- 
ment. In cases where the drum-head is very thick, or where 
the ossicles are bound down by adhesions to the walls of the 
tympanum, no perceptible movement may be obtained at first, 
but decided improvement often follows a persistent use of the 
pneumatic treatment. 

In obstinate cases the progress may be hastened by making 
pressure directly upon the processus brevis by means of a probe 
covered with a soft-rubber tip or Lucre's pressure-probe. Stiff- 
ness in the joints may be overcome in this way so as to facilitate 
the action of the otoscope. One should press gently on the 
process until the handle moves, then retract the probe until the 
malleus resumes its former position, press again, and so repeat 
the movement several times. Then the pneumatic principle of 
the otoscope should be applied until one is satisfied that the ad- 
vantage gained will not be lost. The mallet should be moved 
until the patient experiences a sensation of movement or sound. 
The utility of passive motion, or massage, in the treatment 



96 DISEASES OF THE EAR, NOSE, AND THROAT. 

of stiff joints and atrophied tissues is well recognized in general 
surgery. The application of the same principle to the same 
conditions in aural surgery is also attended with beneficial 
results. Charles Delstanche, of Brussels, has also devised an 
excellent massage instrument. 

The pressure-probe which I devised in 1886, and of which 
I made mention at the meeting of the American Medical Asso- 
ciation in 1888, has been superseded by a much better one de- 
vised by my good friend Professor Lucas, of Berlin. It consists 
of a delicate shank set parallel to its hollow handle by a right- 
angle deviation so as to bring the operator's fingers out of the 
field of vision. The distal extremity terminates in a soft, 
downy cup that fits over the short process. The handle con- 
tains a delicate spiral spring surrounding the proximal end of 
the shank so that pressure on the short process and release of 
pressure should produce a rebound or to-and-fro excursion of 
the hammer-handle without removing the cup from the process. 
This method is painful and causes congestion of the membrana 
flaccida, but is beneficial. Direct pressure on the line of the 
short process is the most effective on the stirrup. If treatment 
by inflation and massage produce redness along the malleal 
plexus of vessels, extending over the greater part of the mem- 
brana flaccida, it should not be used further for that treatment. 

I have found the best results from a systematic plan some- 
what as follows : For the first week or two lavolin is injected 
into the middle ear by means of the improved inflator on Mon- 
day, Wednesday, and Friday, always preceding the ear treat- 
ment with the necessary cleansing and medication of the nose 
and throat. On the intervening days the massage otoscope is 
used sufficiently to obtain as near the normal mobility of the 
ossicles as possible, or until the hypersemia, mentioned before, 
is produced. On the second or third week the treatments are 
gradually separated by intervals of two, three, or four days. 
The lavolin conduces to the softening and rendering pliable of 
the adventitious tissues in the middle ear. When stimulation is 
desired, or the patient or surgeon is in doubt as to the entrance 
of the jet of lavolin into the tympanic cavity, 6 or 10 drops of 



DISEASES OF THE MIDDLE EAK. 97 

sulphuric ether added to the lavolin in the sponges contained in 
the infiator will produce stimulation and a sensation of coolness 
followed by a glow of warmth in the ear, thus demonstrating 
its presence in the tympanic cavity. Richer advocates the 
iodine-vapor inflations and iodized cotton in the external canal. 
Dundas Grant uses a self-inflator charged with chloroform. 

If it should be desirable to produce the effect of camphor- 
menthol on the lining membrane of the tympanic walls without 
carrying a perceptible amount of the menstruum into the cavity, 
this can be accomplished by substituting the dilator (Fig. 18) 
for the infiator, with a 3-per-cent. solution of camphor-menthol 
in lavolin. For the physiological action of camphor-menthol 
see Chapter XVIII. It is but proper to remark that the bene- 
ficial results sometimes afforded by this method are even more 
surprising to the surgeon than to the patient. 

Formerly the author followed in the footsteps of his pre- 
decessors in the employment of fumes from resublimed iodine 
crystals with which to douche the middle ear, but so little per- 
ceptible good and so much irritation attended its use that it has 
had no place for this purpose in his practice for a number of 
years. Pilocarpine, from which so much has been expected by 
some eminent otologists, has proven, after persistent trials, a 
dismal failure in the author's experience. I have tried solutions 
of citrate of lithia, a very soluble form, by injections through 
the Eustachian tube, in the hope that if deposits of urate of 
sodium were present in certain gouty patients, and if the anky- 
losis of the ossicles were due to the presence of this deposit as 
in other joints of the same individuals, it might be dissolved 
out. Carbonate of lithia is known to accomplish similar results. 
The result was nil. Various other solutions and volatile 
medicaments have been projected into the middle ear for the 
relief of sclerosis, but it would be a waste of time and space to 
enumerate most of them. Many are inert, others positively 
harmful. The injection of fluids through the Eustachian 
catheter and tube is a painful process attended with irritation of 
the tnbe and tympanum unless accomplished by exceptionally 
skillful and gentle hands — and no others should attempt it. 



98 DISEASES OF THE EAR, NOSE, AND THROAT. 

Possibly a little tympanic irritation may prove beneficial, but 
the probabilities are in favor of its proving harmful. If hyper- 
emia is desired it can more easily and safely be produced by 
the prolonged use of the massage otoscope and Lucas's pressure- 
probe. The Valsalvan method produces congestion of the 
tympanic tissues, and for that reason patients ought not to be 
taught or allowed to practice it. They receive a certain 
amount of temporary relief; consequently they practice it not 
once or twice a day, but repeatedly, many times a day, until 
the membrana tympani loses its tension, becomes relaxed and 
retracted, and no more relief is had. 

The use of the phonograph, vibrometer, and other expen- 
sive instruments that produce sound-waves of speech, or musical 
vibrations that are conveyed to the drum-head by rubber tubes 
inserted into the external canal, have been vaunted by ill- 
advised laymen ; but experimental investigation only confirms 
what a familiarity with the principles involved presages : their 
utter uselessness. During a discussion of this subject at the 
meeting of the First Pan-American Medical Congress, the 
otologists present, including the distinguished Professor Politzer, 
concurred in these conclusions quite generally. 

It is worthy of attention that the treatment as outlined 
above filters all the air and fluids before they reach the ear. 
All are forced through the finest quality of medicated sponges, 
which offer a resistance to the air-current of about four pounds. 
This fact should be given proper consideration in every treat- 
ment, and all the instruments must be kept scrupulously clean 
and disinfected in order not to commit the unpardonable sin of 
infecting a patient. 

How long shall treatment continue'? Only so long as 
improvement continues. If it is protracted much beyond the 
time indicated, it may be followed by an actual retrogression. 
Too much treatment is pernicious. When improvement takes 
place and a state is reached in which improvement remains 
stationary, despite all efforts for a reasonable time, then treat- 
ment had best cease. The patient should be discharged with 
proper instructions for the care of himself, and for his return 



DISEASES OF THE MIDDLE EAR. 99 

should be begin to lose the gain already made. Indeed, tbese 
unfortunates must be gently, but candidly, informed that, so 
long as life's burden bears upon them, just so long they will 
suffer the necessity of repeating their sojourneys to the aurist 
whenever relapses occur. The invariable question " How long 
must I be treated]" every otologist has to answer. The 
average length of time required varies from one to three 
months. Often the patient will remark that his head feels 
clearer and the noises have diminished or changed in character, 
which is favorable. If but one ear is affected, its early treat- 
ment may prevent the other following in the same route. Or 
if both are affected, if they have not become too seriously 
involved, we may be able to arrest the progress of the disease 
and preserve, if not improve, the present state of hearing. 

The application of the faradic current for ten minutes at a 
time daily for several weeks has appeared to exert a beneficial 
effect in certain cases. I have designed electrodes (Fig. 72) 
adapted to the concentration of the current in the ears, for the 
older ones diffused the electricity over the side of the head. 
The tips of the chamois-covered electrodes are wet and covered 
with a little moistened cotton, inserted into the auditory canals, 
and buckled in place. Then the cables are attached connecting 
the electrodes with the battery. In this manner the patient is 
relieved of the tiresome holding of the electrodes in place. 
However, I do not attach great importance to electricity in 
this disease. 



CHAPTER X. 
DISEASES OF THE MIDDLE EAR, CONTINUED 

Operative Treatment of Sclerosis. 

The author has devised an ossicle-vibrator (Fig. 48) for the 
purpose of breaking up adhesions in the middle ear and anky- 
losis of the ossicles. It consists of a shaft of steel armed with 
two little levers at the distal end, and fashioned at the proximal 
extremity to fit into the angular handle of the middle-ear instru- 
ments. It is used in the following manner : An incision is made 
through the drum-head close to the anterior border of the ham- 
mer-handle and parallel with it from the short process to its tip 
under cocaine. Then the end lever, which is curved for the 
purpose, is carried through this slit and behind the mallet, 






Fro. 48.— The Author's Ossicle-vibrator. 






when the handle falls between the two little levers. Then they 
are slipped along upward embracing the handle until the 
stronger part of the bone is reached and the levers fit the handle 
somewhat closely. Now the retracted handle is slowly and very 
gently drawn upon until it is felt to move, or until the adhesions 
are felt to give way, and to the extent of bringing the handle 
to its normal position. The gentlest care must be had or the 
adhesions may give way very suddenly with a jerk and the 
mallet might possibly be dislocated, or the handle might be 
fractured, especially if the instrument were allowed to slide 
downward upon the weaker portion of the handle. I have not 
known these accidents to attend the use of my instrument, but 
one can conceive that they are within the range of possibilities. 
Again, a patient has become pale just as the adhesions yielded 
(100) 



DISEASES OF THE MIDDLE EAR. 



101 



to the traction, and fainted. This was probably due to the dis- 
turbance of the intra-labyrinthal fluid as exaggerated motion 
was effected in the stirrup. Some most remarkably beneficial 
results have followed the use of this simple method of mobili- 
zation of the ossicles. No harm has been known from it. 
After making the incision and before introducing the vibrator, 
it conduces to the comfort of the patient to instill a few warm 
drops of 10-per-cent. cocaine solution. 

Incision of the posterior fold of the drum-head is indicated 
when there is great sinking inward of the membrane, with fore- 
shortening of the mallet-handle, and prominence of the short 
process, with a stretched appearance of the membrane about it. 
This condition, associated with serious impairment of hearing 
and head noises that are unimproved by the treatment already 




Fig. 49.— Section of the Posterior Fot,d of the JIembhaka Tympani. 
(After I'olitzer.) 



detailed, calls for this simple operation. The section is best 
made about midway in the folds (Fig. 49) and the knife (Fig. 
53, No. 2) is made to cut from above downward with care that 
it is not carried deeper than is required to sever the fold. Other- 
wise the chorda tympani may be severed and paralysis of taste 
produced (Figs. 50 and 51). Although I have made such sec- 
tions frequently, I have never known this to follow, but such 
results are reported. Patients generally observe a sense of relief 
from pressure, clearness in the head, diminishing of subjective 
noises, and sometimes improvement in hearing. In the class 
of cases in which I have mostly practiced this operation I have 
not been able to follow up the results for years, but have known 
the benefit in a few to persist for several years. In others of a 
worse type the improvement has been transient. 



lO'J 



DISEASES OF THE EAR, NOSE, AND THROAT. 



Multiple incisions of the drum-head have proven beneficial 
in some instances. In 1886 T reported the results of a series 
of cases to the meeting of the American Medical Association, 
from which I quote: "For the purpose of making a crucial test 
of the efficacy of this procedure, I have made it the last resort 
in those cases which afforded no real hope for relief from any 
other treatment. Perhaps the propriety of operating on those 
patients that seemed to promise no results might be questioned, 
were it not for the facts that in nearlv all of them there was an 







Fig. 50.— Internal Surface of the Left JMembrana Tympani. (After Politzer.) 

a, head of the malleus; b, neck of the malleus; c, tendon of the musculus tensor 
tympani and anterior fold of the inembrana tympani; d, inferior extremity of the 
handle of the malleus: e, anterior portion of the inembrana tympani; /, chorda tym- 
pani and posterior fold of the membrana tympani ; g, incus ; h, short process of the 
incus : i, long process of the incus. 



unexpected improvement and that no unfortunate consequences 
followed the operation. The cases I have chosen to operate on 
were far more hopeless than those with chronic suppurative 
inflammation. The consideration that the former respond so 
little to our efforts, while the latter are so amenable to treatment 
with inflations, cleansing, peroxide of hydrogen, boric acid, 
bichloride of mercury, etc., with the result of not only arresting 
the disease, but of improving the hearing, has led me to seri- 
ously contemplate the advisability of establishing the suppura- 
tive process in proliferous inflammation of the middle ear. In 



DISEASES OF THE MIDDLE EAR. 



103 



three cases only in my practice has this condition followed the 
procedure under discussion, and the results in the series of cases 
reported were satisfactory, especially when it is considered that 



/ 6 k 




Fig. 51.— Vertical Section- of the External Meatus, Hekbbana Tympani. 
and Tympanic Cavity. (After Politzer.) 

a, cellular spaces in the superior wall of the meatus connected with the middle 
ear: 6, roof of the tympanic cavity: c. inferior wall ; d, tympanic cavity: e. membrana 
tympani : /, head of" the malleus : g, handle of the malleus ; h, incus : i'. stapes ; k. Fal- 
lopian canal : 1, fossa jugularis : />;. apertures of glands in the external meatus. 

they were the most unpromising and had proven the most in- 
tractable to the usual methods of treatment. But, as remarked 
above, this experimental work, which was carried out mostly in 
dispensary practice, did not afford opportunities to follow up 




Fig. 52.— Teiaxgulae Resection of the Drum-head. (After Politzer.' 



the results for a number of consecutive years. The simple in- 
cision, of course, closed in a few days, but the tension of the 
drum-head apparently was restored to more nearly the normal." 



104 DISEASES OF THE EAR, NOSE, AND THROAT. 

Another method that I have since pursued with consider- 
able success was the excision of areas of the drum-head, usually 
triangular in shape (Fig. 52). Under cocaine I made triangular 
flaps with the apex above, and then severed the attached base, 
removing this piece of the membrane entire. It was sometimes 
easiest after making the two sides of the triangle to grasp the 
apex witli delicate forceps in one hand while the base incision 
was made with the other. The improvement in some patients 
in whom there was no labyrinthal disease was very gratifying, 
and in private patients I was able to demonstrate the possibility 
of maintaining the aperture for a considerable time. In one in- 
stance it had remained open a year and a half when the patient 
removed from the State. A peculiar experience was had with 
the other ear. The first operation afforded so much improve- 
ment that he requested that the same operation be performed 
on his right ear. It was done, and a slight, muco-purulent dis- 
charge followed, but soon ceased. While the discharge lasted, 
the hearing was considerably improved and the tinnitus relieved. 
After the discharge ceased the hearing began to diminish, when 
he expressed regret that the ear had not continued moist. This 
led me to moisten it with warm, pure vaselin, but when I 
re? moved it a few days afterward the very large perforation was 
entirely closed. 

The removal of sections of the drum-membrane may prove 
otherwise advantageous. It affords accessibility to the tympanic 
cavity for the instillation of various remedies and the destruc- 
tion of the adhesions, and it reveals whether the entire resection 
of the drum-head would improve the hearing. In case the 
membrane is so thickened and sclerosed and infiltrated with 
calcareous deposits as to preclude the possibility of its respond- 
ing to any except extraordinary sound-waves, and the labyrinth 
is not involved, the opening of a window in the drum-head will 
admit sound to the stirrup and to the round window and prove 
whether the entire absence of the membrane would prove reme- 
dial. If the adhesive process has not ankylosed the stirrup in 
the oval window nor invaded the round window, vibrations can 
reach the labyrinth if the barrier to their admission be removed. 



DISEASES OF THE MIDDLE EAK. 105 

I have employed this test to determine whether excision of the 
entire drum-head would afford successful results. 

Division of the tensor tympani tendon is not much in favor 
among American aurists. The indications for it are not clearly 
defined, and the appearances that suggest the shortening of this 
muscle — retraction of the membrana tympani and foreshortening 
of the mallet-handle — are also just as characteristic of the pres- 
ence of membranous folds and bands of adhesion. The results 
of tenotomy have been either so unsatisfactory or so positively 
detrimental that the operation is not encouraging. Greene and 
Pomeroy prefer a blunt-pointed knife curved on the flat to sever 
the tensor tympani. 

EXCISION OF THE MEMBRANA TYMPANI AND OSSICLES. 

This operation for sclerosis is a subject concerning which 
there is probably less unanimity of opinion among otologists 
than any other. While a few American aurists, especially Bur- 
nett, Sexton, Blake, and Jack, have been enthusiastic advocates 
of the operation, and some others have followed their lead for a 
time, the majority appear to have receded to a more conserva- 
tive position. At the meeting of the section of Otology at the 
Tenth International Medical Congress in Berlin in 1890 the 
Continental leaders in this specialty expressed themselves in 
very conservative terms on the subject. Several years ago the 
writer, through the columns of the Journal of the American 
Medical Association., invited all who had performed this opera- 
tion to communicate the results to him for the purpose of pub- 
lishing a collection of experiences that would afford a just esti- 
mate of the average value of this operation. The responses 
were so few and so unsatisfactory as to force the conclusion that 
the operation was either little practiced or was disappointing. 
There is probably little or no diversity of opinion concerning 
the utility of the operation in suppuration of the middle ear, 
especially when there is ossicular necrosis ; but as practiced for 
sclerosis there has been so much division of opinion and sad, 
disappointing experiences reported during the past ten years that 
candor requires that the subject be treated with reference to both 



1(H) DISEASES OF THE EAR, NOSE, AND THROAT. 

the ill and the good results. A number of cases have been 
under my observation upon whom the operation has been per- 
formed by surgeons both East and West, with the effects of 
producing a suppuration of the middle ear, destroying the hear- 
ing, apparently intensifying the noises, and producing more or 
less vertigo. At the present time I have under treatment a 
physician from a far-western State whose ossicles were removed 
from one ear by an aural surgeon several years ago. All the ill 
results enumerated followed the operation, and, although the 
hearing was two inches for the watch before the operation, that 
ear lias been totally deaf since, and the opposite ear has deteri- 
orated. This is a fair type of numerous similar instances that 
have come to my personal knowledge, and under the observa- 
tion of other physicians who have been kind enough to report 
them to me. 

Wiirdemann had the courage to report several similar 
results at the meeting of the American Medical Association 
in 1892. It is worthy of mention that nearly all of these 
unfortunate cases were operated upon by specialists in eye and 
ear diseases ; so that the results cannot be attributed to the 
want of familiarity with the subject. It is not our purpose to 
inveigh against this procedure as an operation, but to emphasize 
the necessity not only of the utmost precision and gentleness in 
operating, but also the most painstaking preliminary examina- 
tion and experiments to determine the possibility or otherwise 
of beneficial results. For example, if the hearing- tests demon- 
strate that the labyrinth is involved in the disease, the inutility 
of the operation is established. If no improvement follow a 
resection of a portion of the drum-head so as to admit sound- 
waves to the fenestrse leading to the internal ear, no help can 
be expected from excision of the whole membrane. We do not 
lose sight of the fact that by removing the drum-membrane and 
the two larger ossicles we are afforded access to the stirrup so as 
to mobilize it. Some advantage certainly is to be conceded to 
this measure, although mobilization of the stirrup is not as 
simple an act as one might believe. Even with every vestige 
of the membrane removed, the stirrup is situated so high that a 



DISEASES OF THE MIDDLE EAR. 107 

good view of it is difficult to obtain, and I have found it easy 
to dislocate when it was not ankylosed. 

OPERATION FOR EXCISION OF THE OSSICLES. 

The ear should be prepared by syringing with a warm solu- 
tion of bichloride of mercury, 1 to 1000, and the instruments 
should be immersed for three minutes in boiling soda-water. 
For several years past the author has used ether to the exclu- 
sion of chloroform, instructing the anaesthetizer to administer 
only so much as is absolutely necessary to secure quiet and 
freedom from suffering. Cocaine anaesthesia is not as effective 
as ether. After removing all debris of any nature from the 

j — > c 



i>* 



33 



32 



' rT —~* 1 




Fig. 58.— Middle-Ear Instruments and Handle. 

canal, it is dried and closed with absorbent cotton until the 
operation commences. If ether is used, the patient must occupy 
a recumbent position. I use tables high enough to bring the 
patient's ear opposite my eye as I sit facing the table. A brilliant 
illumination is needed. I have used mostly the Argand gas- 
lamp and light-condenser (Fig. 5) or the sixty-candle-power 
Welsbach gas-burner. One will have a clearer view of the field 
of operation if the room is darkened so that no light penetrates 
the operator's eye except that reflected from the ear-cavity. 

The instruments necessary (Fig. 53) are a paracentesis- 
knife (Xo. 2) ; a blunt-pointed bistoury (Xo. 1) ; two angular 
knives, right and left (Xos. -4 and 5) ; two ossicle-hooks, right 



108 DISEASES OF THE EAR, NOSE, AND THROAT. 

and left (Fig'. 54); a pincette (Fig. 5b); a dozen cotton-carriers 
armed with cotton; a quart of hot, sterilized water, and a 
syringe. 

The operation proceeds as follows : The drum-head is in- 
cised near the periphery, behind the short process of the mallet. 
Into this opening- the blunt-pointed knife (No. 1) is inserted 



"W 



FiG. 54.— The Author's Ossicj.e-iiook. 

and carried first below, then sweeping the lower and the an- 
terior attachments until the roof is reached; then this attach- 
ment is severed until the whole circular incision is completed, 
ending at the first entrance. The knife is best carried first from 
above downward for the reason that less haemorrhage is likely 
to obstruct the view than if the more vascular membrana flao 
cida were first cut. There is less haemorrhage also if the knife 
is kept a little way from the periphery of the membrane. Now 




Via. 55.— Poutzer's Pincette. 



the angular knife is used to separate the articulation of the 
anvil and stirrup (Fig. 51). The anvil is extracted by aid of 
the hooked probe, and the attachments of the mallet are then 
divided, when it is brought away with the pincette. Stacke 
detaches the auricle and removes the integumentary canal first. 
The operation is a very short one, requiring but a few 



DISEASES OF THE MIDDLE EAR. 109 

minutes ordinarily if there is not much haemorrhage or if the 
adhesions are not embarrassing. Rapid use of the cotton-car- 
riers, which should be kept prepared by a nurse, will keep the 
field quite clear; but in case of considerable bleeding the syringe 
and quite hot water can be brought into requisition. It is dif- 
ficult to avoid severing the chorda tympani, but the resulting 
paralysis of taste is of short duration. The ear-cavity should 
be dried after bleeding has ceased, covered with a layer of aristol 
from the small powder-blower (Fig. 32), and the canal closed 
with iodoform gauze. While there is considerable reaction in 
some cases, followed by discharges of a muco-purulent character, 
in others there is little or no disturbance. The patient should 
be kept quiet, and his diet restricted until healing takes place. 
By properly restricting the diet both before and after the oper- 
ation, there is less tendency to regeneration of the drum-head. 
The latter occurrence is quite frequent. In the case of the 
physician just spoken of there is a false drum-head which I 
have not removed, for the reason that no possible good could 
come of it. 

In another case of a very robust man from Kansas I re- 
moved the third adventitious membrana tympani, at his request. 
In the spring of 1893 a surgeon had removed his drum-head 
and mallet. In seven days after the operation he says the drum- 
head had been reproduced. This was removed, and in seven 
days more the surgeon said that another had closed the tym- 
panum. A third operation was had, and in fourteen days 
another drum-head had formed. Two years afterward the 
patient came to me with the request that I remove this remain- 
ing fourth drum-head with which nature had supplied him. He 
suffered from great tinnitus and uncomfortable sensations of 
pressure, etc. Examination revealed labyrinthal involvement 
and I discouraged the procedure. But, notwithstanding the 
assurance that no improvement was to be expected, the patient 
insisted upon the operation, with the hope that it might afford 
some relief to the tinnitus and pressure-symptoms. Therefore 
I removed the drum-membrane and anvil at the Post-Graduate 
Medical School and Hospital, June 21, 1895, and cauterized 



110 DISEASES OF THE EAR, NOSE, AND THROAT. 

the periphery of the drum-head so as to completely destroy the 
whole circular attachment. A few days afterward I found the 
stirrup dislocated and removed it. No unfavorable symptoms 
followed ; the membrane has not been reproduced, and the 
slight discharge following the operation soon ceased. The ear 
has remained in good condition ever since, but, although the 
patient imagined himself better, I could discern no improvement. 
The tinnitus and other symptoms were neither removed nor 
considerably improved. The patient thought he could hear, 
but accurate tests proved the contrary. This case is instructive 
in showing that the thorough galvano-cauterizing of the periph- 
eral attachment of the membrane will prevent its regeneration. 
I do not often employ this cautery in the ear on account of the 
great heat generated in so minute an inclosed space, but the 
chromic acid has too superficial an effect to accomplish the 
purpose. 

While I mention these unfavorable cases, — and I might cite 
others who have come under my care, one of whom is the most 
distinguished of American editors, — it is not for the purpose of 
condemning the operation itself, for I believe that these unfortu- 
nate results are attributable either to an unwise selection of 
cases or to unforeseen accidents attending the operation. For 
example : Why should two inches of hearing for the watch be 
exchanged for total deafness, vertigo, etc. ] The results point 
toward an injury to at least one of the fenestras opening into 
the labyrinth. But the reverse of this picture presents some 
excellent and even brilliant results. Some cases that have 
proved intractable to the usual measures have yielded to this ; 
but these are the ones in which the labyrinth has not been 
involved, and the adhesive process has not destroyed the useful- 
ness of the stirrup and membrane of the round window, and in 
which excision of a small section of the membrana tympani 
would demonstrate the possibilities of the operation. Barclay, 
Sexton, Burnett, Blake, and Jack favor excision of the ossicles. 
Gleason {Atlantic Medical Monthly, March 23, 1895) severs the 
incudo-stapedial articulation to improve hearing in sclerosis. 

Mobilization of the stirrup has been practiced with favor- 



DISEASES OF THE MIDDLE EAR. Ill 

able results, especially by Jack ; but the crura of the stirrup 
are so exceedingly delicate and fragile that they are quite 
likely to break on applying side-pressure to them or on trac- 
tion with the hook. This maneuvre is not in favor with 
otologists generally. After the membrana tympani has been 
removed for sclerosis the conditions are most favorable for 
mobilization. The probe can then be introduced alongside the 
stirrup and pressure exerted in all directions to break up ad- 
hesions and effect mobility. The hook can then be engaged in 
the apex of the converging legs of the bonelet and drawn upon 
until slight motion is had. But if the adhesion give way 
suddenly, the stirrup will be dislodged or extracted unless great 
care is exercised. 

Excision of the ossicles for persistent suppuration is a 
common practice among otologists, especially in the case of 
caries and necrosis of these bones or of the walls of the tym- 
panic cavity. Great cleanliness must precede these operations, 
which can more easily be accomplished under a 20-per-cent. 
solution of cocaine than in dry catarrh. I have often operated 
under cocaine without any difficulty, especially when the 
patients were possessed of considerable self-control. The same 
instruments and methods are employed as in sclerosis. If much 
curetting of the bone is necessary, a general anaesthetic (ether) 
had better be used. 

Out of twenty-two cases of stapedectomy reported by 
Blake there was only one improvement, and in this the fixation 
of the stapes was not complete. Some became worse after the 
operation both as to hearing and tinnitus. In five cases vertigo 
came on and persisted. Stapedectomy is now disapproved of by 
Blake, Cozzolino, and Gelle. 



CHAPTER XL 

DISEASES OF THE MIDDLE EAR, CONTINUED. 

Chronic Suppurative Inflammation of the Middle Ear. 

This is a common sequel of acute suppuration and fall of 
Import to the afflicted patient. While the laity, and unfortu- 
nately certain members of the medical profession who are not 
well informed upon the consequences of the disease, minimize 
its importance and advise that it be let alone and that children 
will outgrow it, the patient's life may pay the penalty of its 
neglect. The disease may outgrow the patient. The close rela- 
tions of the tympanic and cranial cavities should suggest to the 
mind of- every thoughtful physician the importance of prompt 




Fig. 5;i.— Extensive Destruction of the Drum-head. (After Politzer.) 



and skillful interference with the progressive destructive ravages 
of the suppurative process. It is not self-limited; it does not 
tend toward resolution, but toward dissolution, and no trifling 
makeshift is pardonable. 

Pathol o<j if. — The whole tympanic cavity is usually affected, 
the mucous membrane being hypertrophied and reddened, or 
yellowish and leathery in appearance. It seems unnecessary to 
remark that a perforation in the drum-head always exists, and 
in cases of long standing the opening is likely to be quite large 
and to afford some view of the interior of the cavity (Figs. 56 
and 57). 

The membrana tympani is rarely completely destroyed, and 
in those instances in which the destruction is quite extensive 
(112) 



DISEASES OF THE MIDDLE EAR. 



113 



(Fig. 58) the membrana fiaccida remains. The rupture of the 
membrane takes place most frequently in the lower posterior or 
anterior quadrant, but may be found in Shrapnell's membrane, 
— a very unfavorable location with reference to drainage. If the 





Fig. 57.— Pear-shaped Perforation of 
the Drum-head. (After Politzer.) 



Fig. 58. — Perforation of the Pos- 
terior Half of the Right Drum- 
head. (After Politzer.) 

Behind the raallet is the projecting, 
yellowish-gray promontory : above it the 
long crus of the incus lying free and the 
posterior crus of the stirrup. 



perforation appear above the 
short process of the mallet, we 
suspect necrosis of this bone. 
The instances are not infrequent in which the whole lower, 
or tense, membrane is destroyed, while the loose membrane 
from the short process upward is intact. The hammer-handle 
projects downward, free from any membrane except perhaps 
a border on each side of the upper half of the handle (Figs. 




Fig. 59.— Destruction of the Inferior 
Half of the Membrana Tympani, 
Laying Bare the Promontory and 
Niche of the Round Window. 
(After Politzer.) 




Fig. 60. —Large Perforation of the 
Right Drum-head. (After Politzer.) 

The handle of the mallet is free and the 
long crus of the incus and the niche of the 
round window are visible. 



59 and 60). This gives an excellent view of the inner wall 
of the cavity and of the long leg of the anvil and the stirrup 
if they are present. 

When the ossicles participate in the necrotic process, the 
anvil is the first to succumb in three-fourths of the cases. This 



114 DISEASES OF THE EAR, NOSE, AND THKOAT. 

Is to be accounted for by its poorer blood-supply. Its nutrition 
is easily cut off by any pressure in tbe upper part of the 
tympanum. 

In long-standing suppuration, and more especially when 
the destruction of the drum-head is extensive, there occurs a 
shedding of superficial epithelium of the middle-ear membrane, 
which takes on an epidermic character; so that it presents the 
appearance of skin rather than mucous membrane. This prob- 
ably is brought about by an extension or growth inward of the 
epidermis of the canal through the perforated membrane, or 
cholesteatoma. 

While the perforations of acute suppurations generally close 
spontaneously after the discharge ceases, they more often remain 
more or less permanently open after the chronic suppuration is 
cured. In a long course of suppuration the destruction of the 
membrane is far more extensive than in the acute or transitory 
variety. Yet we often come upon elderly people who show un- 
mistakable evidences of extensive loss of tissue of the membrane 
that lias been repaired by nature ; large sections in the lower 
posterior or anterior quadrant, or in both, that consist of trans- 
lucent, thin, cicatricial tissue, surrounded by the ashy-gray, 
leathery tissue of the old membrane. These people are "many 
times unconscious of ever having had a discharge from the ear, 
but upon investigation the fact may be established that it 
occurred beyond their remembrance, during childhood. 

The disease may extend to the labyrinth, although it is not 
of frequent occurrence. It far more often invades the mastoid 
antrum and cells. If we recall the position of the antrum be- 
hind the middle car, and their connection by the aditus ad 
antrum, and then the relative positions of these cavities when 
the patient lies upon his back, we shall appreciate how the 
fluids in the tympanum may drip through the passage and enter 
the antrum. It is like the changing of the battery-fluid from 
one part of a Kidder-tip battery-cell to the other by turning 
the cell upon its axis. It is apparent from these considerations 
that mastoid disease is a logical consequence of middle-ear 
suppuration. 



DISEASES OF THE MIDDLE EAR. 



115 



Etiology. — From what has already been said it is seen that 
this affection is only an extension of the acute suppurative 
process in most instances, the causes of which are enumerated 
in Chapter VIII. Neglect of an acute disease generally results 
in a chronic one. A tubercular or syphilitic habit of body 
predisposes to this condition. 

Symptomatology. — The presence of a purulent discharge 
issuing from a perforation in the drum-membrane is a simple 
matter to discern. The pus may be abundant or very scant. I 
have under treatment a case of about twenty years' standing in 
which not more than a drop or two will exude in a day. For 
a few days or a week there may be no discharge, and then a 
foul-smelling exudation is found. In other instances there is 




Fig. (51.— Destruction of Inferior Half of the Drum-head. Globular 
Granulations on the Inner Wall of the Middle Ear. (After Politeer.) 



not enough purulent discharge to run out of the canal, but in- 
stead it dries in scales or yellow crusts on the walls of the canal. 
As these crusts of inspissated pus work toward the mouth of the 
canal they cause itching and consequent annoyance. 

The hearing may not be seriously impaired. It does not 
deteriorate so generally nor to such a degree as in sclerosis. 
Still, the hearing is greatly affected in occasional cases. Crusts 
may form over the perforation, obstructing the discharge and 
impairing hearing, but patients do not often complain of sub- 
jective noises. 

Granulations often form on the border of the perforation 
and over the surface of the intra- tympanic membrane (Fig. 61). 
Large, cherry-red, spongy granulations sometimes may cover 
the inner wall like a cushion. They are sensitive and bleed 



IK) DISEASES OF THE EAR, NOSE, AND THROAT. 

readily. Polypi occasionally spring from the membrane and 
occupy the canal. A single polypus often fills the canal 
ami extends to its mouth. I have seen them grow to such pro- 
portions that the pressure upon the canal-walls interfered with 
the circulation of the part projecting from the mouth of the 
canal to the extent that its color was livid or black, suggestive 
of gangrene. We also have multiple aural polypi of luxuriant 
growth and of the form of a cauliflower. These are usually of 
a bright-red color. If the pus in which the polypus is macer- 
ating is carefully removed without irritating the polypus, the 
latter presents sometimes a very pale, exsanguinated surface, 
but upon friction it assumes a bright-red color and bleeds upon 
touch. 

Caries. — Carious bone is to be suspected whenever granu- 
lations or polypi exist. The minute, bent probe may detect de- 
nuded bone in the tympanic cavity. The anvil is occasionally 
lost, and, if the external wall of the aquseductus Fallopii, con- 
taining the facial nerve, is imperfect or necrosed, facial paralysis 
of the same side will occur if the pressure is sufficient, or the 
nerve itself may participate in the inflammation. If necrosis 
of bone is present, the odor of the discharge is generally very 
offensive, even when care is taken of cleanliness. With neglect 
of the discharge it may become very foul, even when there is 
no osseous necrosis. Invasion of the labyrinth is ushered in 
by sudden dizziness, deafness, and nausea. Fortunately this is 
very rare. 

Diagnosis. — If the description given be borne in mind, 
there is no difficulty in deciding upon a case of chronic suppu- 
ration of the middle ear. The long-standing discharge from a 
perforation of the drum-head makes the case clear. 

Prognosis. — This is a progressively destructive disease. 
Its tendency is not to spontaneous resolution. While many 
attacks may appear to get well of themselves, so long as the 
diseased condition remains, just so long recurring attacks will 
succeed each other. Witli every fresh cold, back comes the 
flux. The disease continues, though no discharge may make 
its appearance, and the patient is lulled into a false sense of 



(DISEASES OF THE MIDDLE EAR. 117 

ecurity. A slight exciting cause sets up another exacerbation 
>f the existing inflammation. Moreover, the natural tendency 
>f this trouble is toward the bone. The mucous membrane of 
he middle ear answers the purpose of a periosteum, and the 
intimate relation of these structures jeopardizes the integrity of 
the osseous tissue when destructive processes are going on in the 
membranous lining. It has also been shown that mastoid sup- 
puration is an offspring of middle-ear inflammation. The same 
may be said of phlebitis and sinus-thrombosis, meningitis, 
subdural abscess, pyaemia, and abscess of the brain. Only 
with proper treatment is the prognosis good. 

Treatment. — More brilliant results are obtained here than 
in the adhesive catarrhal form of inflammation. The first object 
is absolute cleanliness. This is best obtained by syringing the 
ear with at least a quart, or more if necessary, of sterilized 
water, or bichloride solution, 1 to 5000, as warm as is comfort- 
able to the patient. Unless a considerable quantity is used, all 
of the inspissated, greasy debris often found in a neglected 
suppurating ear is not removed. As much force as can be 
easily borne is generally required at the first cleansing, to 
remove all the discharges from the middle ear. The water 
need not be thrown with so strong a current as to produce 
giddiness or nausea. The continuous-flow syringe, like the 
alpha (Fig. 31), is the most satisfactory, as it admits of most 
perfect control over the temperature of the water and the force 
of the current. The stream is directed a little toward the roof 
of the canal, rather than directly in a line with its axis, so as to 
return along its floor. The patient, if an adult, can hold some 
conveniently-shaped receptacle pressed closely against the side 
of the neck just beneath the lobule to catch the returning 
solution. The water once injected into the ear must under no 
circumstances be re-injected. I have found people (physicians !) 
committing that act. Crusts, inspissated pus, and cerumen not 
expelled by the water can be removed with cotton or a blunt 
probe. Delstanche has devised a tympanic syringe to inject 
the attic. 

After cleansing thoroughly with the syringe, the ear is 



1 1 8 DISEASES OF THE EAR, NOSE, AND THROAT. 

inflated so as to eject any possible secretion remaining in the 
Eustachian tube or middle ear. The parts are then dried with 
absorbent cotton, and a coating of aristol is dusted over the 
surface of the middle ear with the small powder-blower (Fig. 32) 
or boric acid with the large powder-blower (Fig. 62). Aristol 
is the first choice on account of its antiseptic, anaesthetic, and 
cicatrizant properties. It never causes pain and does not inter- 
fere with the hearing by clogging the canal or impeding the 
movements of the drum-head and ossicles. If the discharge 
does not show perceptible decrease in the course of a week or 
two, it is advantageous to substitute boric acid for the aristol 
or to throw a coating of boric acid over the aristol dressing. 
This can be done without dislodging the latter, for it sticks 




Fig. 62.— The Author's Large Powder-blower. 

tenaciously to the surface of the tissues. This adds the drying 
effect of boric acid to all the excellent qualities of aristol, and 
constitutes an ideal treatment for such individuals as we have 
mentioned who have an idiosyncrasy against boric acid. I 
have met a few such instances with this disease, although they 
are oftener encountered among the acute cases. After the first 
few treatments of this kind it is advisable to resort to an 
entirely dry method, relying on the absorbent-cotton driers, 
inflation, and the powders, for cases often do much better with 
the dry than with the wet method. The discharges often 
cease after three or four treatments, and occasionally after the 
first one. The results of painstaking methods are more sur- 
prising to the surgeon than to the patient, who may have been 
harassed for long years with annoying discharges. 



DISEASES OF THE MIDDLE EAR. 119 

Many other remedies are commonly used, but it is the 

Liithor's purpose to give what years of experience have proven 

be most efficacious and to inform the practitioner upon the 

relative merits of those that have been given extensive trials. 

iome will be mentioned merely for the purpose of saving the 

Oder's time in experimenting with the useless. 

Iodoform in fine powder is useful when the odor of the 
ischarge and other signs indicate the presence of dead bone ; 
otherwise it is not preferable to aristol, and its disgusting odor 
is usually very objectionable to fastidious people. The old-time 
remedy, silver-nitrate solution, was formerly extensively used in 
my clinics, but for many years I have not employed it. Having 
tried it in solutions varying in strength from 1 per cent, to a 
saturated solution, it became apparent that its remedial qualities 
in this disease were inferior to remedies less objectionable. The 
blackening of everything it touches renders it especially dis- 
advantageous in private practice. Zinc sulphate exerts too 
little influence to merit our confidence. Salicylic-acid powder, 
highly recommended a few years ago, has proven, in my hands, 
a total failure. Moreover, the violent irritation of the hares and 
attacks of sneezing its unavoidable inhalation produces during 
the insufflation would preclude the possibility of its employment, 
were it not otherwise impotent. Europhen is valueless in this 
disease. I have persisted in experimentation with it alone and 
combined with aristol, and am forced to the conclusion that the 
total value of europhen-aristol lies in the latter ingredient. 
Indeed, the aristol alone is more potent. After extended trials 
with yellow pyoktanin no appreciable effect could be observed 
in arresting the discharge, and the same is true of dermatol, 
alumnol, and iodol. 

Let us suppose now that we have a more intractable type 
of suppuration. The mucous membrane lining the tympanic 
cavity appears very red, suggestive of the glow of dull, red-hot 
iron ; it is much thickened and tumefied ; the drum-head par- 
takes of the same characteristics, is very sensitive to the touch, 
and shows rhythmic pulsations. These characteristics obtain 
in a small proportion of old cases. It is difficult to adapt the 



120 DISEASES OF THE EAR, NOSE, AND THROAT. 

dry method of treatment to such conditions, for the touching 
of the drum-membrane with the cotton to absorb the discharges 
is productive of great pain. It is best then to syringe and allow 
all the water to run out ; then dioxide (peroxide) of hydrogen 
( 1 1 ,0.,) is warmed slightly, only sufficiently to make it comfort- 
able to the ear, and is used to fill the canal While the head is 
inclined to the opposite shoulder. Or, better still, the patient 
lies upon the opposite side. Warming the dioxide to the tem- 
perature of the body does not impair its efficacy, as I have often 
demonstrated. It is allowed to remain in the ear until efferves- 
cence ceases. This requires about five or ten minutes, accord- 
ing to the amount of pus present and the purity of the remedy. 
It must not have a strong acid reaction or it will cause pain, 
and it should contain not less than fifteen volumes of available 
oxygen. The dioxide decomposes pus-corpuscles, during which 
action free oxygen is liberated to exert its germicidal property 
upon bacteria. Besides this the active effervescence that takes 
place dislodges debris, and its mechanical action brings to the 
surface materials that even syringing fails to dislodge, — for ex- 
ample, aristol that may have remained from a previous treat- 
ment. This boiling out of the middle ear appears to cleanse 
the attic even better than the intra-tympanic syringe, and no 
unpleasant results have ever attended my use of it. 

In suspected retained discharges in the attic or mastoid 
antrum, especially when the perforation is too small to admit 
of free drainage, it should be enlarged as already described in 
the preceding chapter. But there are frequent instances in 
which the discharge does not diminish after thorough efforts at 
cleansing, disinfecting, and medicating. This failure may be 
owing to the impossibility of the means employed to remove all 
the retained secretions and the consequent failure of the medic- 
aments to reach the diseased surfaces to a large extent. The 
author has devised an instrument to meet this condition. It 
consists of an improved miniature air-pump (Fig. 63), contain- 
ing a metallic valve that does not get out of order, fitted to a 
glass reservoir. The tip of the reservoir is covered with a soft- 
rubber tube so as to permit of its being fitted with firmness and 



DISEASES OF THE MIDDLE EAR. 121 

nicety into the external meatus. A gentle traction on the 
piston-ring exhausts the air in the middle ear and accessory 
chambers and causes the ejection of any discharges within them 
into the canal, whence they are removed with the cotton absorb- 
ent. After the piston is moved the whole length of the cylinder 
once or twice the instrument is removed and the canal inspected. 
Then, after drying it of the secretions brought to view, the proc- 
ess is repeated two or three times. When no more discharges 
can be drawn from their hiding-places, it is safe to conclude that 
all have been evacuated. The traction need not be rapid nor 
strong enough to occasion discomfort or the exudation of any 
blood; although, if the latter occur, no harm is done, for the 
discharges are the more thoroughly swept away and the tissues 
are stimulated. The instrument is held in such a way as to 
grasp both air-pump and receiver in the fingers at the same 




Fig. 63.— The Author's Ear-aspirator 



time, so as to prevent their being separated while the pump is 
in action. In order to satisfy myself as to the value of this 
simple device, I have given the most thorough treatment by the 
old methods without diminishing the discharges, and then have 
resorted to this treatment in addition to the old methods, with 
the result of stopping the flux promptly. In such cases, after 
cleansing as much as possible by syringing, the dioxide, etc., I 
have applied the aspirator and drawn an astonishing quantity 
of discharges that must, from their amount and character, have 
been stored in the mastoid antrum and cells, and these cases 
have recovered without mastoid operations. 

MacBride (Edinburgh Medical Journal, June, 1895) opens 
the mastoid process and middle ear to cure chronic suppurative 
inflammation, and Jones (Liverpool Medico- ChirurgicalJournal, 
July, 1894) advocates excision of the ossicles. 



CHAPTER XII. 
DISEASES OF THE MIDDLE EAR, CONCLUDED. 

Sequels of Middle-Ear Suppuration. 

granulations. 

The presence of granulations in the middle ear or on the 
drum-head protracts the cure. If they are small and not very 
extensive, they can he made to shrink up and disappear by the 
use of alcohol. At first it is advisable to dilute the alcohol 
one-half. In the event of no pain being caused by that it can 
be used stronger, and if the patient easily bear it the full 
strength should be employed. The period in the treatment 
to use it is just after the cleansing process is finished, and 
the alcohol should remain in- the ear ten minutes or longer. 
After it runs out the granulations that appeared very red before 
its application are blanched to a pale-gray color after the con- 
tact of the alcohol for a sufficient length of time. Then the 
treatment should be completed with the powders as before. 
When the granulations are very large and abundant, suggestive 
of beginning polypi, these are best removed by the curette 
under a warm, 20-per-cent. solution of cocaine. The bleeding- 
is stopped by pressing a pledget of cotton against the curetted 
surface for a few minutes, a few drops of cocaine solution is 
used on them, and then the alcohol as before. Chromic acid 
may also be employed as described in the next paragraph. 

POLYPI. 

Suppuration cannot be cured so long as a polypoid growth 
is present. This is best removed under cocaine by a polypus- 
forceps (Fig. 64) or the snare found in the middle-ear case 
(Fig. 65). It requires less skill to use the forceps. The 
polypus should be detached as close to the attachment of 
its pedicle as possible, and, the method being so simple and 
identical with the same procedure in other fields of surgery, it 
(122) 



DISEASES OF THE MIDDLE EAR. 



123 



is un necessary to enter into the details here. The bleeding 

ceases soon and can be stanched as described in treating of 

granulations. Then cocaine is applied and the attachment 

cauterized with chromic 

acid. Tlie loop of the 

caustic applicator (Fig. 

66) is dipped into the 

dry crystals of chromic 

acid and these are held 

over a small flame for a 

few seconds until they 

are melting. Just at the 

instant the crystals are 

fused in the form of a drop on the most convenient site of the 

loop for application the instrument is withdrawn from the heat 

and the drop of fused acid blown upon to cool it suddenly into 




Fig. 64.— Politzek's Polypus-fokceps. 




Fig. 65.— The Author's Middle-Ear Case. 



a bead. Unless the attachment of the polypus is well cauter- 
ized it is likely to grow again. It can be removed with a 
fenestrated curette of good size, like the larger one in the 
middle-ear set, by placing the curette so as to engage the 



124 DISEASES OF THE EAR, NOSE, AND THROAT. 

pedicle in the aperture. Then, by pressing firmly against it 
and drawing outward, it is detached and extracted. 

CARIES AND NECROSIS OF THE MIDDLE EAR. 

When the tympanic walls are denuded of their lining mem- 
brane, which is, in effect, its periosteum, the treatment requires 
much patience and persistence. After cleansing by water, dioxide 
of hydrogen, and the aspirator, as outlined, a 12-per-cent. solu- 
tion of carbolic acid in glycerin is poured into the ear. This 
does not require warming. After it has remained long enough 
to produce the anaesthetic effect of the acid — about six minutes 
— it is removed and replaced by a saturated solution of iodoform 
in alcohol. If the solution is agitated so that some of the powder 
is held in suspension, so much the better, for when the solution 
is allowed to run out after five or ten minutes a fine coating of 



Fig. 66.— The Author's Caustic Applicator on Flexible Shank. 

iodoform powder is left covering the diseased tissues. This solu- 
tion penetrates the diseased cavities deeply. Then the treatment 
is completed as already described for suppuration. In cases 
where denuded bone could be felt with the probe, this method 
has effected cures. Indeed, sequestra of necrosed bone may have 
been cast off and discharged with the pus, leaving the living 
bone to become healed over by granulation. But if dead bone 
be present it acts as a local irritant similarly to a foreign body, 
and must be removed with the curette before healing will take 
place. A foul odor, notwithstanding scrupulous cleanliness in 
the treatment, indicates the presence of osseous necrosis. As 
long as this foul odor continues the discharge cannot be stopped, 
but the disappearance of the odor is a very favorable symptom, 
as H. Gradle has shown. Persistence in this treatment will 
often remove the odor and discharge. There are occasionally 
persons with whom the alcoholic solution of iodoform does not 
agree. The integument of the canal becomes swollen, tender, 
and excoriated, and the toxic iodoform must give way to other 



DISEASES OF THE MIDDLE EAR, 



125 



remedies. The bichloride of mercury occasionally is not well 
borne, and if used in too strong a solution a similar condition 
ensues, and even ulceration of the integument. 

NECROSIS OF THE OSSICULA. 

The anvil, the first to yield to the necrotic process, is some- 
times lost before patients apply for treatment, but when it is 




a c 
Fig. 67.— Vertical section of Middle Ear ; Droi-head in Contact with 
the Inner Wall. (After Politzer.) 

a. ledge-shaped remnant of the membrane : 6. c, the lateral portions of the cicatrix, 
extending; from the remnant of the membrane to .the inner wall of the tympanic cavity ; 
d, portion of the cicatrix applied to the inner wall. 

present and is diseased it should be removed. The same is true 
of the mallet. In such cases they are of no value to the 
patient, and only serve to excite a continuation of the inflam- 




Fig. fr?.— Band-like Cords Between the Lower End of the Hammer- 

HANDLE AND THE STAPEDO-INCEDAL ARTICULATION. (After Politzer.) 



matory process and to hinder the free evacuation of the retained 
secretions. Their excision, if skillfully accomplished, does not 
impair the hearing and may conserve it. The question of their 
removal in this instance is not a parallel case to that in sclerosis. 
The operation is described in Chapter X, 



V2i\ 



DISEASES OF THE EAR, NOSE, AND THROAT. 



Adhesions of the remnant or of cicatrices of the membrana 
tympani to the inner wall of the tympanic cavity may occur 
after the suppuration is cured (Fig. 67). This results in a 
cup-shaped depression in the drum-head. Adhesions and false 
membranes also form within the tympanum, subdividing it 
into several cavities (Fig. 68). Connective tissue and chalky 
deposits (Fig. 69) sometimes fill completely the middle ear, im- 
bedding the chain of bones so firmly that their functions are 
entirely destroyed. In case the adhesions cause serious impair- 
ment of hearing by embarrassing the vibrations of the ossicles 
or by preventing sound-waves from reaching the labyrinth, 
they can be divided or excised. Connective- tissue formations 
and cretaceous deposits can be treated like cholesteatomatous 
masses, which are considered later. 




Fig. 



-Central Perforation of the Drum-head and Calcareous 
Deposits. (After Politzer.) 



PERFORATIONS OF THE DRUM-HEAD. 

Perforations, if they are large, generally remain open and 
require no treatment. The edges become covered with a con- 
tinuation of the epidermis of the drum-head. The membranous 
lining of the middle ear becomes habituated to the presence of 
air that reaches it directly through the meatus, so that it 
acquires a tolerance for it, like the nasal mucous membrane. 
The hearing remains better with than without the perforation, 
but there are exceptional instances in which the hearing is im- 
proved by closing the perforation with cotton or a thin rubber 
disc. The latter exceptions can be treated by freshening the 
edges of the perforation after the discharge ceases, and covering 
the aperture accurately with a moist disc of sized paper. The 



DISEASES OF THE MIDDLE EAR. 127 

presence of this foreign body will excite sufficient irritation to 
increase the circulation in its vicinity to the extent of causing a 
proliferation of cells, growth of granulations, and consequent 
closure of the opening. But the cases are rare in which the 
patient's interest is best subserved by closing the perforation, for 
the remainder of the drum-head is usually opaque, hypertro- 
phied, or calcified (Fig. 69) and leathery; so that it is unfitted 
for transmitting sound-waves. With an opening through it the 
vibrations have direct access to the foot-plate of the stirrup and 
the membrane of the round window, and through them reach 
the perceptive apparatus. 

Artificial drum-heads should receive mention in this con- 
nection. I have seen a few persons who believed they were 
able to hear better with discs or cones of soft rubber inserted 
so as to lie in contact with the membrana tympani ; but the 
remote ill effects more than counterbalance the immediate ap- 
parent increase in hearing-power. When there is suppuration 
they impede the outward flow and promote decomposition of the 
discharge. In any event, they act as foreign bodies, giving 
rise to irritation and resulting increase in connective-tissue 
formation. This increased thickening of the drum-membrane 
insures a still greater decrease in hearing. 

DEAFNESS FOLLOWING SUPPURATION. 

Deafness following suppurative inflammation calls for treat- 
ment after the suppuration ceases. Politzerization to overcome 
adhesions between the ossicles or drum-head and the walls of 
the tympanum may be practiced three or four times a week. 
Better still, if the perforation has closed, is the method of throw- 
ing a spray of lavolin into the middle ear with the improved in- 
flator (Fig. 24). The lavolin takes the place of the discharge, 
and it is commonly observed that the hearing is better while 
the middle ear remains moist. The lavolin is a bland, non- 
irritating liquid vaselin, and does not become rancid like oil. 
It softens the dried and hardened tissues, increases their supple- 
ness, and promotes greater freedom of mobility. This injection 
is followed by the use of the massage otoscope (Fig. 8). The 



128 DISEASES OF THE EAR, NOSE, AND THROAT. 

drum -head is caused to make a dozen or more excursions, with 
the endeavor to approximate as nearly as possible the natural 
limits of movement. This is after the fashion of the machinist, 
who first oils his machine and then works it. This method is 
best pursued for three or four weeks, or as long as perceptible 
progress is made in improvement, and then discontinued. As 
long as the benefit obtained is stationary the ear had best be let 
alone. It is well to instruct these patients that when retrogres- 
sion sets in they should return for further treatment. 

Tinnitus is not a very common symptom in purulent 
inflammation, but it is an occasional sequel of that trouble. 
The treatment just detailed for the deafness is the best adapted 
for this condition also. 

CHOLESTEATOMA. 

In this disease there is an excessive growth of epidermis in 
the external auditory canal and desquamation of epithelial cells 
in the middle ear. Lumps of epidermis and shiny, pearl-like, 
little masses are found, both during and after suppuration. 
Bezold believes them to be the result of an extension of epider- 
mic formation from the external canal to the middle ear. Lucas 
reports a case without any suppurative process. Virchow believes 
they are true heteroplastic tumors. 

The epidermis of the external meatus spreads over the 
walls of the middle ear, and even invades the mastoid antrum 
in rare cases, but the latter is the result of excessive prolifera- 
tion of epidermis accompanied with exfoliation. The concre- 
tions are of a caseous appearance, containing, besides epithelial 
cells, fat-globules, bacteria, and crystals of cholesterin. 

The mastoid process is more often the seat of these masses 
than the tympanic cavity. They increase to a large size as the 
bone is destroyed, either by advancing caries or necrosis or as 
the result of absorption due to pressure. 

The diagnosis is not difficult if the excessive formation 
and desquamation of epidermis are noticeable in the external 
meatus, and if the epidermic masses are visible in the middle 
ear through a perforation. Chunks of foul-smelling, gritty, 



DISEASES OF THE MIDDLE EAR. 129 

cheesy particles may be found in the washings from the ear. 
The perforations are most likely to be found in ShrapnelPs 
membrane, for the growth of epidermis inward is marked on 
the upper Avail of the canal. Long continued and obstinate 
suppuration is characteristic of this disease. The masses 
constitute a dam against the free exit of the discharges, and 
decomposition of pus and the growth of polypi are encour- 
aged. This condition forms a fruitful soil for the propagation 
of bacteria. 

When the cholesteatoma is situated in the tympanic attic 
or in the mastoid antrum the diagnosis is difficult, if not 
impossible, to determine, unless the masses disintegrate and are 
evacuated during the cleansing treatment, or unless the mastoid 
cortex breaks down and exposes the condition present. If the 
diagnosis can once be positively made out, the question of oper- 
ative measures is settled. The methods of treatment are found 
under the headings of " Chronic Suppuration " and " Mastoid 
Operations." Bezold advises epidermic transplantations in 
cholesteatomatous cavities, after the Thiersch method. 

FACIAL-NERVE PARESIS AND PARALYSIS. 

Impairment or loss of function of the facial nerve is due to 
a variety of causes. The facial canal and neurilemma may par- 
ticipate in a middle-ear inflammation ; ulceration and necrosis 
of the bone may involve the nerve ; an exudate, a callus, a 
sequestrum, or a tumor may produce pressure ; syphilitic or 
other central nervous disease may exist at the origin of the 
nerve, or traumatic injury may partly or wholly paralyze it. 
The lower branches supplying the nose, side of the face, and 
angle of the mouth are generally more affected in paresis from 
the mastoid operation than the upper branches distributed to 
the orbicularis palpebrarum. But in some cases the forehead 
and face are for a time seriously affected, even when the eye can 
be closed completely, but slowly, and with an effort. 

The same side of the velum palati may be involved in the 
paralysis. If the muscles of the side of the face and angle of 
the mouth are paralyzed, the patient cannot drink liquids 



130 diseases of the ear, nose, and throat. 

without their escaping from the lips ; he cannot inflate the 
cheeks without the air escaping from the paralyzed corner of 
the mouth ; in laughing the face is drawn to the unaffected 
side, giving a crooked appearance to the countenance (Fig. 70). 
The facial expression is entirely lost on the side that is par- 
alyzed. The inability to close the eye exposes it to winds, 
sunlight, and dust, resulting in chronic conjunctivitis. 

Recovery may be expected from paresis due to an acute 
inflammation of the Fallopian canal and the sheath of the facial 
nerve secondary to middle-ear inflammation, and from slight 
injuries to the nerve during mastoid operations (Fig. 71). 
Paralysis, or complete loss of conduction of the nerve, resulting 
from caries or necrosis of the facial canal, or from division of 
the nerve during the operation, presents an unfavorable prog- 
nosis. In this condition the eye cannot be closed. 

Dench says : " Injury to the facial nerve is not a serious 
accident, function being restored in from three to five weeks, in 
most cases, under the use of the faradic current." The author 
is not in accord with this view. If the whole calibre of the 
nerve-trunk is not affected, but only certain bundles, spontaneous 
resolution may occur and complete restoration of function in 
three or six months, but I have never seen a case of recovery 
take place after complete, total paralysis of all its branches had 
occurred from injury to the nerve during an operation. I have 
seen varying degrees of interrupted transmission in the different 
branches of the nerve, with corresponding variations in the re- 
covery. The eye being the least and the side of the face and 
mouth next least affected would recover completely, while the 
occipito-frontalis remained powerless, giving a noticeable droop- 
ing effect to the eyebrow. 

On the other hand, I have had paresis affecting all the 
branches, occurring after the operation for excision of the os- 
sicles through the meatus, recover completely after the use of 
the galvano-faradic current for three or four months. 

In the course of the nerve which is most exposed to trau- 
matism during the mastoid operation the bundles distributed to 
the obicularis oris, the muscles of the side of the face, the 



Fig. 70.— Appearance in Facial Paralysis, the Patient Laughing. 




Fig. 71.— Same as Fig. 70, Three Months After Stacke Operation and 
Treatment with Electricity. 



DISEASES OF THE MIDDLE EAR, 



131 



l€cipito-fr on talis, and the corrugator supercilii seem to lie ex- 
ternal to the fibres composing that part of the anterior temporal 
branches that supply the orbicularis palpebrarum, for the latter 
muscle is the least affected in operative paresis and the first to 
regain its function. 

Treatment of facial paresis and paralysis depends upon 
the lesion present. If the latter is an acute inflammation with 
exudation, upon the subsidence of the inflammation and the 
absorption of the exudate recovery takes place. If pressure of 
pus on an exposed nerve in middle-ear suppuration or if a 
sequestrum produce the pressure, either must be removed. If 
syphilis is the cause, iodides and mercurials must be employed 




Tig. 72.— The Author's Ear-electrodes, Attached to Band. 

on general principles. Sexton mentions facial paralysis due to 
dental irritation. 

These cases recover after a course of electricity, the current 
being used from the primary coil of a faradic battery. The 
negative pole is applied to the ear of the affected side by means 
of the ear-electrode (Fig. 72), and the positive to the opposite 
ear or mastoid region, then to the groups of affected muscles, 
causing perceptible, though not painful, contractions in them. 
Such a treatment should be given three or four times a week, 
continuing ten minutes. This prevents muscular atony or 
atrophy, while the nerve regains its tone. 

After the mastoid operation the electric current can be 
applied directly to the injured section of the facial nerve by sat- 
urating a pledget of absorbent cotton with sterilized water or 



132 DISEASES OF THE EAR, NOSE, AND THROAT. 

hydrogen dioxide, placing it in the bottom of the wound, and 
connecting the ear-electrode directly with this. The other pole 
is then applied to the trunks of the several branches of the nerve 
distributed to the groups of muscles affected. If one is not 
familiar with these points he can readily determine them by 
applying the facial electrode to the opposite side, observing what 
areas need to be touched in order to contract the desired muscles. 
In Fig. 102 No. 1 shows the point where the electrode will 
affect the infra-orbital, malar, and temporal branches of the 
facial nerve. These supply the muscles of the forehead, the 
orbicularis palpebrarum, and the muscles of the face, nose, and 
upper lip. No. 2 shows the point where the electric current will 
reach the buccal and supramaxillary branches distributed to the 
buccinator and orbicularis oris and muscles of the lower lip and 
chin. 

CARIOUS PROCESSES IN THE TEMPORAL BONE. 

These do not characterize a large percentage of the cases 
of middle-ear suppuration. They are sometimes due to tuber- 
culous and other constitutional taints. While very small areas 
are likely to be affected, they may extend to involve the whole 
temporal bone. Scarlatina is one of the most frequent causes, 
but syphilis and typhoid fever may also give rise to them. The 
pneumatic portion forming the mastoid process is the most often 
affected. Next in frequency come the tympanic walls and ad- 
jacent tissues. The anvil and sometimes the head of the mallet 
are attacked by the necrotic process. 

Pain is a pretty constant symptom of caries except in 
tuberculous individuals, the amount of pain being determined 
by the extent of periostitis or interference with the discharge of 
pus. Other distressing symptoms in addition to pain char- 
acterize this condition : dizziness, noises, nausea or vomiting, 
insomnia, and fever. The discharge is disgusting, often bloody 
and irritating. Granulations and polypi are commonly found, 
and the ossicles may be dislocated so as to wash out when the 
ear is syringed, together with sequestra of dead bone (Fig. 73). 
The meatus may be involved, — swollen or ulcerated. If the dis- 
ease attack the inner tympanic wall, the external wall of the 



7 / f 10 n il 

/3 /* /J 



Fjg. 73.— Sequestra of Dead Bone, and the Ossicles. Actual, Size. 

(Author's specimens.) 

The smooth surfaces of the walls of the tympanic cavity and of the meatus are 
shown in Nos. 1, 2, 3, U, 5, 6, and 11 ; 13, mallet ; IL, anvil ; 15, stirrup. 



*<!Ek. 




» 











Fig. 74.— Post-mortem Section of the Temporal Bone, Showing a Perfora- 
tion of the Lateral, Sinus at 1. Borders of Sinus Bounded by Black 
Lines. (Author's specimen.) 



DISEASES OF THE MIDDLE EAR. 133 

Fallopian canal may be destroyed, exposing the facial nerve to 
pressure or to the inflammatory process, resulting in facial 
paresis or paralysis of the same side. 

Exfoliation of the cochlea takes place in rare instances. 
Hichey reports two such cases. Goldstein {Annals of Oph- 
thalmology and Otology, April, 1895) reports a case of exfoli- 
ation of the cochlea, vestibule, and semicircular canals. 

Toeplitz {Archives of Otology, No. 2, 1892) reports a case 
of primary labyrinthal necrosis with facial paralysis and deaf- 
ness from scarlet fever. During the suppurative process two 
sections of the cochlea were exfoliated and removed through 
the external auditory canal. 

The diagnosis of necrosis or caries is not an easy affair 
unless it can be seen or felt. The probe may detect it if within 
reach, but the denuded bone may be defended by a growth of 
granulations forming a more or less complete carpet. Great 
caution is required in probing not to displace the little bones or 
open up the labyrinth to the introduction of pus. If the treat- 
ment detailed under the caption " Chronic Suppuration of the 
Middle Ear " does not succeed, after a considerable time of per- 
sistent effort, in diminishing and finally stopping the foul dis- 
charge, it is safe to infer a carious condition of the bone. Caries 
is especially dangerous when the roof of the middle ear is its 
seat, for it may terminate in a rupture which will admit the 
pus into the cranial cavity. When the pyramid is invaded 
the hearing is destroyed and an unfavorable prognosis must 
be given. 

Erosion of the carotid canal may occur, or of the lateral 
sinus, with fatal haemorrhage. Such a case of destruction of the 
carotid canal came under the care of Dr. James R. Davey, in the 
Illinois Charitable Eye and Ear Infirmary, recently which re- 
quired ligation of the common carotid artery. Repeated copious 
haemorrhages occurred from time to time, which could only be 
stopped by packing the meatus. Complete recovery followed 
ligation of the common carotid artery. 

Another method of termination is an extension of the 
caries to the cranial cavity and lateral sinus, or it may excite 



134 DISEASES OF THE EAR, NOSE, AND THROAT. 

suppurative meningitis or phlebitis, or end in brain-abscess. A 
perforation of the inner table of the mastoid process may allow 
the pus to filter into the current of blood in the lateral sinus, 
producing- pyaemia. I have such a typical specimen in my col- 
lection (Fig. 74). 

This was the case of a man with mastoiditis for whom I 
advised an operation. The physician in attendance deferred 
the operation until, when it was performed, the patient was 
suffering profoundly from pyaemia. A hopeless prognosis was 
given. Autopsy revealed the perforation of the lateral sinus 
shown in the foregoing figure, through which the purulent 
contents of the mastoid cells were flowing. Fig. 104 is the 
same mastoid process as Fig. 74, showing where the fistula 
(No. 2) opened beneath the tip of the process and the attach- 
ment of the sterno-cleido-mastoid muscle, resulting in an ab- 
scess of the neck, located underneath this muscle. No. 3 shows 



ffrflSM*!, 





Fig. 75.— The Author's Middle-Ear Curette. 

the opening made by a small trephine directly into the antrum, 
in which the probe rests. No. 4 is a tuft of cotton in the ex- 
ternal auditory canal. There is no doubt that this patient's 
life could have been saved had the operation been submitted to 
when it was first advised. 

The treatment includes thorough cleansing and disinfecting 
of the suppurating cavities and removal of granulations or 
polypi, as detailed in the foregoing pages. Anodynes must be 
given for severe pain. The denuded, roughened bone, if within 
reach, should be scraped free of all carious tissue with the 
middle-ear curette (Fig. 75), but only the most delicate resort 
to such procedure should be bad in case the caries is located on 
the inner tympanic wall, for it is thin and easily perforated when 
carious (Fig. 76). After curetting, the treatment as detailed 
for chronic suppuration is called for. 

Sequestra are removed with ease or difficulty according to 
their size, shape, and location. Patients sometimes present 






DISEASES OF THE MIDDLE EAR. 



135 






pieces of dead bone that have become exfoliated and appear in 
the syringing process. I have removed quite a large sequestrum 
from a boy 4 years old by means of cotton on a holder. During 
the examination the cotton used for drying out the ear was 
observed to become engaged in the angular spiculae of a seques- 
trum. So it was twisted firmly into them and drawn upon, 
with the result of extracting the quite large sequestrum com- 
pletely (Fig. 73, No. 2, actual size). Other sequestra (actual 
size) from various cases are shown in the same figure. When 
the sequestra are too large and irregular to extract through the 
meatus without inflicting unwarrantable injury, they may be 




/ 



ac b g 

Fig. 76.— Horizontal. Section of the Ear. (After Politzer.) 

a, anterior wall of the osseous meatus ; 6. its posterior wall ; c, section of the mem- 
bran a tympani, of the handle of the malleus, and of the posterior pouch ; d, promon- 
tory ; e, ostium tyinp. tubae ; /, stapes in connection with the inferior extremity of the 
long process of the incus and of the tendon of the stapedius ; g, mastoid process ; h, 
cochlea ; i, vestibule; k, carotid canal. 



crushed by sequestrum forceps and removed in fragments. 
When an extensive sequestrum cannot be removed through the 
natural channel and suppuration cannot be cured, and especially 
if urgent or dangerous symptoms supervene, it is advisable to 
open the mastoid process and remove as much of the posterior 
wall of the meatus as is required to extract all the dead bone. 
The diseased surface should then be curetted, dressed, and 
treated as detailed under " Mastoid Operations. ,, 

The general condition of the patient may call for tonics 
and alteratives, which will readily occur to the general prac- 
titioner. 



CHAPTER XIII. 

EXTENSION OF EAR DISEASES TO THE CRANIAL 

CAVITY. 

Intra-CRANIAL complications of suppuration of the middle 
ear take place in the following ways : By an extension of the 
carious process in the temporal bone to the cranial cavity, with 
evacuation of pus into the latter ; by extension through the 
vessels and fenestra? that penetrate the bone, resulting in puru- 
lent meningitis ; by the formation of a subdural or brain- ab- 
scess, and by septic involvement of the venous sinuses, resulting 
in phlebitis, thrombosis, embolism, and septicaemia. 

Meningitis. 

Symptomatolog y . — Severe and continuous headache, local- 
ized or general, increasing in intensity and accompanied with 
photophobia, generally characterizes the onset of this disease. 
There are nausea or vomiting, sleeplessness, loss of memory, 
general hyperesthesia, dullness of intellect, and in children 
delirium and convulsions of the face (same side) and extrem- 
ities. In the advanced stage opisthotonos may occur. The 
pupils are firmly contracted at first, afterward dilated and not 
responsive to bright light, but they are sometimes unequal. 
The temperature, like many of the other symptoms, is not con- 
stant, but it varies from 101° to 105° F. The pulse is accel- 
erated at first, becoming slower by cerebral compression, and 
later again increasing. The respiration is irregular and jerky 
in inspiration, followed by a pause, and in expiration of a 
lengthened, sighing character. Hemiplegia or paralysis of one 
or more extremities may occur, and when the third, fourth, or 
sixth nerve is involved strabismus follows. At last the power 
over the bladder and bowels is lost, the respiration is accelerated, 
the pulse rapid and compressible, and finally general paralysis 
is followed bv coma and death. 
(136) 



EXTENSION OF EAR DISEASES TO THE CRANIAL CAVITY. 137 

Diagnosis. — This is, many times, difficult to determine, 
especially in children. The elimination of any other affection 
in the course of a purulent inflammation of the middle ear, the 
occurrence of constant fever, headache, and vomiting constitute 
the most important diagnostic points. Add to these the signs 
of injection of the retinal vessels and often neuritis, and the 
diagnosis is rendered quite certain. 

Prognosis. — Without operation, death. 

Treatment. — If cold is agreeable the ice-cap should be con- 
tinuously applied, bromidia given for pain, and the bowels 
opened. If a specific infection is suspected, iodide of potassium 
is indicated. The great fatality warrants an early surgical 
operation, which is described under its proper title. 

Subdural Abscess. 

This is a localized accumulation of pus hemmed in by ad- 
hesions of the meninges to the internal table of the skull. It 
generally results from a slow extension of the disease of the 
tympanic cavity through the thin partition of the bone separat- 
ing the latter from the cranial cavity. 

Symptomatology. — There is generally some fever, intense 
pain over the temporal bone, and the symptoms of meningitis ; 
exacerbations are followed by improvement after a sudden dis- 
charge occurs from the ear. The abscess is not located in any 
part of the motor tract ; so that no localizing symptoms appear. 
The temperature rarely rises above 102° F. Tenderness over 
the painful area is usually present. When the cerebellar fossa 
is invaded, giddiness and vomiting may be expected. 

Diagnosis. — This is obscured, as appears from what has 
been said, by the indefiniteness of the symptoms. The points 
in diagnosis are detailed above. 

Prognosis. — This is unfavorable if the abscess rupture in- 
ternally, but if it break externally or is evacuated by operation 
recovery may take place. 

Treatment. — Operative treatment only is effective. It con- 
sists of laying bare the tympanic cavity by the Stacke method 
(see " Mastoid Operations "), evacuating the pus-cavity, removing 



138 DISEASES OF THE EAR, NOSE, AND THROAT. 

all granulations and dead bone, cleansing, disinfecting, and 
dressing with aristol or iodoform and gauze. If no pus is found 
and the cerebral pulsation is absent, as often happens in brain- 
abscess, the aspirator-needle may be used to explore the site of a 
suspected pus collection. 

Cerebral and Cerebellar Abscesses. 

These are the result of a chronic, rather than acute, sup- 
puration of the middle ear. Over one-fourth of all cerebral 
abscesses follow this disease. Twice as many men as women 
are subject to brain-abscesses. They are generally located 
either in the temporal lobe or in the same side of the cerebellum 
as the ear disease (Bergmann). They may be deep-seated or 
superficial, single or multiple, in one or both sides of the cere- 
brum. Caries in the roof of the tympanum usually causes 
cerebral abscess which covers the posterior surface of the 
pyramid, or in the mastoid process causes cerebellar abscess. 
The size of the pus-cavity varies from an eighth of an inch 
(three millimetres) to several inches (centimetres) in diameter. 

Symptomatology. — Bergmann classifies the symptoms of 
such abscesses as follows: 1. Those of suppuration : paroxysmal 
fever, chills, dullness, depression, loss of appetite, indigestion, 
rise of temperature in region of abscess, and tenderness on per- 
cussion. 2. Pressure symptoms : headache, dizziness, uncon- 
sciousness, delirium, twitching and paresis in extremities and 
facial muscles, strabismus, disturbance of vision and speech, slow 
pulse, sleepiness, Cheyne-Stokes respiration, eclamptic attacks, 
and intermissions. 3. Pus in the temporal lobe, with inability 
to speak certain words, is rare. In the cerebellum it produces 
dizziness and a staggering gait. 

The time-limits of brain-abscess are very variable. It may 
exist indefinitely without urgent symptoms. An old abscess 
contained within connective-tissue capsules may remain innocu- 
ous until it ruptures outwardly producing meningitis, or until 
encephalitis supervenes in its vicinity, or it may discharge into 
the ventricle. A fatal issue may result from metastatic abscesses. 
For example, I have seen the whole anterior aspect of the thigh 



EXTENSION OF EAR DISEASES TO THE CRANIAL CAVITY. 139 

converted into an immense pus-reservoir. There is a marked 
predilection for the lungs. The end may be preceded by cere- 
bral compression, great prostration, or paralysis of the respira- 
tory or circulatory centres. 

Diagnosis. — This is sometimes impossible, for the symptoms 
are absent until the end approaches. When the health steadily 
declines without other assignable cause, coupled with otor- 
rhcea, insomnia, constant temperature of about 99° F., localized 
pain in the same side or in the occiput, we are safe, by the 
process of exclusion, in arriving at a diagnosis of this disease. 

Prognosis. — Without operative interference the termination 
is fatal, but the prognosis has been illuminated with the brill- 
iant records of Macewen and Korner, 95 per cent, recovering 
from operations by the former and 60 per cent, of the cases 
compiled by the latter. 

Treatment. — Until a diagnosis can be made, there remains 
little to do except to direct our efforts toward improving the 
general health and relieving temporary symptoms. A surgical 
operation is the only curative measure. 

Operations for Brain-abscesses. 

Referring to the skull (Figs. 89 and 90) that the author has 
prepared to illustrate the various operations for trephining and 
for mastoid diseases, the surgical relations of the parts involved 
will appear. The field of operation is prepared on the previous 
day by shaving and scrubbing with soap and water, and after- 
ward with alcohol or ether, leaving a generous margin hairless. 
Then the head is bandaged with sublimated gauze. The bowels 
are opened by a saline draught on the previous evening and an 
enema on the morning of the operation. Nothing but beef-tea 
is allowed on the same day. While ether is generally to be pre- 
ferred in other operations, chloroform is allowable in this in- 
stance, since it causes a depression of the cerebral centres, while 
ether acts as an excitant. 

The point selected for the centre of the half-inch trephine 
is seven-eighths of an inch above the centre of the meatus 
(Fig. 89). Incisions at right angles to each other are usually 



140 DISEASES OF THE EAR, NOSE, AND THROAT. 

made, intersecting each other at this point, although Horsley 
prefers a semicircular flap. The cut should penetrate to the 
hone, and all the soft tissues are raised, preserving the peri- 
osteum, and retracted by the double hooks (Fig. 88). The 
trephine now having been used, if the opening is not capacious 
enough it can be enlarged without injuring the dura by an in- 
genious device of DeVilbiss, of Toledo, or with the chisel. The 
dura is opened in a valve-shaped flap by a circular incision one- 
eighth of an inch inside the bone-perforation, so as to permit 
of this remaining margin being sewed to the flap of the dura 
afterward if necessary. If there is no cerebral pulsation the 
abscess may be expected to be superficial, but even if pulsation 
is present there may be a deeply-seated pus-cavity. 

The aspirating-needle should now be inserted in the direc- 
tion of the abscess if no pus appear. Or a sharp bistoury may 
be cautiously introduced once or twice or even a third time in 
different places. If pus escape the opening is enlarged, as com- 
plete evacuation as possible is effected, and the cavity is packed 
with iodoform gauze, or a rubber drainage-tube may be in- 
serted. If no pus is found the dura is sutured ; the bone button, 
having been preserved in sterilized warm water, is replaced ; the 
periosteum stitched in situ, the soft parts brought together, and 
the skin wound is closed with the finest catgut. Iodoform 
gauze, absorbent cotton, and a bandage complete the dressing. 

When the abscess is located over the roof of the mastoid 
antrum, the latter is opened, and in most of these cases it is 
filled with either pus or a cholesteatoma. Enough of the roof 
of the antrum is chiseled away to allow of examination of the 
dura. If the latter is covered with granulations or if no pul- 
sation is present, it should be entered. If no pus is found, a way 
is made leading to the roof of the middle ear (Kuster), avoiding 
the facial nerve and semicircular canals by going above the 
former and in front of the latter. An incision is then made in 
the middle portion of the temporal lobe. The after-treatment 
is described above. Knapp (Archives of Otology, April, 1895) 
performs the tympano-mastoid cranial operation for otitic brain- 
abscess. 



EXTENSION OF EAR DISEASES TO THE CRANIAL CAVITY. 141 

Cerebellar abscesses may be reached by chiseling the mas- 
toid process so as to penetrate the posterior fossa without opening 
the lateral sinus, or the trephine may be used so as to perforate 
the occiput between the occipital and the lateral sinuses (Fig. 
89, v). It should not be forgotten to always give a very 
guarded prognosis. Besides the causes of fatal termination 
already mentioned the end may be hastened by haemorrhage 
from the middle meningeal artery, gangrene of the brain, 
pyaemia, and prolapsus of the brain. Zaufal (Archives of 
Otology, April, 1895) first opens the posterior fossa, and if 
results are negative then the middle fossa, if the cranial cavity 
is to be opened after a mastoid operation. 

Sinus-phlebitis and Sinus-thrombosis. 
These complications result from caries or necrosis of the 
posterior tympanic wall in a considerable proportion of cases, 
but the lateral sinus is the vessel most often affected. The 
superior petrosal and cavernous sinuses and the internal jugular 
vein are rarely involved, the latter in caries of the inferior 
tympanic wall. While the cause is generally an extension of 
the necrotic process of the bone to the walls of the sinus, phle- 
bitis may also result from septic infection transmitted by the 
veins communicating with the sinus. We may have accom- 
panying this condition cerebral abscess or meningitis. The 
preceding suppuration has generally, but not always, been of 
long duration. The attack is sudden and characterized by pain 
in the occipital region and neck, chills, loss of appetite, and a 
temperature above 104° F., with remissions. The pulse is rapid, 
the skin dry, the tongue dry and coated, but consciousness 
may or may not be affected. Occasional symptoms are dizziness, 
stiffness of the muscles of the neck, optic neuritis, vomiting, 
delirium, convulsions, coma, and others suggestive of septicaemia. 
When the internal jugular vein is affected, a dense cord, tender 
on pressure, may be distinguished along the anterior border of 
the sterno-mastoid muscle if the neck has not become too 
cedematous. If the cavernous sinus is involved the oedema may 
extend to the face, nose, and eyelids. The fatal termination, 



\V2 DISEASES OF THE EAR, NOSE, AND THROAT. 

which often occurs in about three weeks, is most likely to result 
from pulmonary pyaemia. However, the duration varies greatly 
from a few days to months. Recovery cannot be expected 
without surgical interference. 

Treatment — Stimulants, nourishing diet, and antipyretics 
are indicated until the operation is decided upon. The mastoid 
process should be opened (see " Mastoid Operations ") and the 
sinus laid bare. If it has not the natural dark-blue color or 
pulsation, but is hard, thickened, and inflamed, a thrombus is 
probably present. If a broken-down thrombus or pus is present, 
there will be fluctuation and absence of pulsation. The aspi- 
rating-needle should be inserted to ascertain the nature of the 
contents. If either condition mentioned is found, the sinus 
should be laid open vertically with a sharp bistoury, cleaned 
out with forceps and curette, washed with bichloride solution, 
1 to 2000, and dressed with iodoform gauze. 

If the internal jugular vein is thrombosed, it should be 
ligatedlow enough in the neck to get below the thrombus. The 
upper segment is brought out of the wound and the thrombus 
removed and treated as already indicated. This will prevent 
infection of the lungs if resorted to early enough. 




Fig. 



-Interior of Base of Skull.. (Author's specimen.) 



LS, lateral sinus ; //, parallel lines over the superior semicircular canal; O, internal 
auditory meatus ; X. opening by trephine for abscess over the middle ear. The cranial 
fossae and sinuses are shown. 



CHAPTER XLV. 

DISEASES OF THE MASTOID PROCESS. 

Pathology. — Primary acute inflammation of the mastoid 
process is a rare disease. Any affection of this part is nearly 
always consequent upon a middle-ear inflammation. The 
disease may be limited either to the lining membrane of the 
pneumatic spaces or to the periosteum, or both membranes may 
be involved. In the acute form the latter condition is most 
likely to prevail, especially when it is consecutive to an acute 
middle-ear suppuration. Unless the inflammatory process is 
speedily interrupted, necrosis of the bone may occur, with a 
growth of unhealthy granulations ; the formation of a fistula, 
either externally through the cortex, presenting a post-aural 
abscess, or through the posterior wall of the bony meatus (Fig. 
90), or internally, communicating with the cranial cavity 
through the lateral-sinus wall (Fig. 74) or through the roof of 
the tympanic cavity. In this manner the posterior or the 
middle fossa (Fig. 77) may be invaded by the purulent dis- 
charge, thus giving rise to meningitis, subdural abscess, sinus- 
thrombosis, pyaemia, or brain-abscess. Moos {Archives of 
Otology, July, 1894) reported a case of " mastoid disease ex- 
tending outward by way of the mastoid fissure, the continuation 
of the petrosquamous suture." 

In the more favorable cases the discharge contained within 
the antrum and cells may find exit through the middle ear and 
external canal, or, if pus form beneath the mastoid periosteum, 
the resulting post-aural abscess may rupture spontaneously. 
This often occurs when the pus has found its way from the 
antrum through a fistulous opening in the cortex ; so that the 
mastoid antrum comes into direct communication with the ex- 
ternal world. Twelve years ago I treated such a case in a lady 
nearly 80 years old. The discharge had ceased and there was 
a fistulous opening, surrounded by the blackened, exposed bone 
three-eighths of an inch (one centimetre) in diameter, leading 

(143) 



144 DISEASES OF THE EAR, NOSE, AND THROAT. 






into the tympanic cavity. The hearing for conversation was 
not lost, no inconvenience was suffered, and she did not wish 
the opening to be closed. The patient remains in excellent 
health at the present time. 

An occasional result of inflammation of the mastoid cells 
is a proliferation of osseous tissue, which fills and obliterates 
the pneumatic spaces, leaving the whole area a dense, ivory-like 
mass. I have seen a few such processes in which no pneumatic 
cells could be found, and the chisels were bent and chipped as 
though driven against stone (osteosclerosis). 

Etiology. — Primary mastoiditis may occur as the result of 
traumatism or exposure to cold. Generally mastoid disease is 
a complication and is most prevalent during influenza epidemics. 
In the latter case, at least, it is probable that a bacterial infec- 
tion occurs through the Eustachian tube from the respiratory 
passages, since it has been demonstrated that the diplococcus of 
pneumonia is present in the mastoid discharge (Scheibe). 

It should be borne in mind that the relations of the antrum 
and middle ear, being connected by the aditus ad antrum, or 
passage from the tympanic attic to the antrum, are such that 
any fluid in the tympanic cavity naturally gravitates into the 
mastoid antrum when the patient reclines upon his back. 
Indeed, the antrum is the drip-cup of the tympanum, and 
whenever there is considerable fluid in the ear it finds its way 
into the antrum. This does not of necessity imply an inflam- 
mation of the pneumatic cells, but when micro-organisms — 
streptococci, etc. — are present the danger to the integrity of the 
lining membrane and delicate cellular structures is apparent. 

Symptomatology. — Acute mastoiditis is accompanied with 
pain, which, though slight and annoying at first, becomes violent 
and exhausting as the disease progresses. After a few days the 
tongue becomes coated and the temperature elevated two or 
three degrees. If there is periostitis there are also tenderness, 
redness, and swelling over the mastoid region. Pain is some- 
times referred to the temporal, the supra-orbital, or the occipital 
region. Fluctuation denotes either a subperiosteal abscess or a 
fistula. Great fluctuations in temperature during the day 









DISEASES OF THE MASTOID PROCESS. 145 



should excite suspicion of sinus-thrombosis ; but, as descriptions 
of intra-cranial complications have already been given (Chapter 
XIII) , they will not be repeated here. A most noticeable sign 
of mastoid periostitis and oedema of the overlying structures is 
a pronounced prominence of the auricle, which stands out at a 
right angle to the side of the head. 

Pain is not always present in mastoid disease, especially 
after the acute stage has passed, and one must not expect to 
find the whole group of symptoms present in every case. They 
are not constant. Great destruction may take place in the 
process without proportionate discernible manifestations. This 
demonstrates the insidious and dangerous character of the 
disease. If there is no discharge from the ear in acute 
mastoiditis of the cells, one may expect to find a bulging drum- 
head, and the postero-superior wall of the meatus may be 
found depressed. 

The inflammatory process may continue for several weeks 
with recurrences and remissions of the symptoms, but the closest 
watch must be kept in order that any impending invasion of 
the cranial cavity may be averted by prompt surgical inter- 
ference. Pus may invade the middle fossa through the tym- 
panic roof or antrum. If it break posteriorly from the middle 
ear or mastoid cells, it reaches either the lateral sinus or the 
posterior fossa. If it advance anteriorly from the middle ear, 
it may form a superficial abscess in the neck or a retropharyn- 
geal abscess. It may break through the inferior surface of the 
mastoid process and form an abscess beneath the sterno-mastoid 
muscle (Fig. 104). If it find an outlet through the inferior 
surface of the temporal bone, it may burrow beneath the deeper 
layer of muscles even to the thoracic cavity. When the cer- 
vical tissues become infiltrated in the region of the sterno- 
mastoid muscle, or an abscess of the neck forms, the head 
becomes more or less fixed, the face everted, and movements 
involving this muscle are restricted and painful. When a retro- 
pharyngeal abscess is present the jaw is fixed and cannot be 
moved or depressed sufficiently to examine the tongue or throat 
except with great pain. 



10 



146 DISEASES OF THE EAR, NOSE, AND THROAT. 

Diagnosis. — In acute mastoiditis the symptoms enumerated 
are so prominent and characteristic that no difficulty presents 
in recognizing the condition, but in chronic suppuration of the 
mastoid cells, in the absence of a fistula, it is not so simple a 
task. Persistent discharge notwithstanding the treatment, foul 
odor, bulging of the postero-superior wall of the canal, tender- 
ness over this region, and impaired nutrition indicate a mastoid 
disease. 

Prognosis. — Uncomplicated acute mastoiditis subject to 
early treatment presents a favorable outlook. A large propor- 
tion of such cases will recover without an operation ; but the 
treatment must be instituted promptly in order to prevent ex- 
tensive destruction of the bone and intra-cranial complication. 
When the latter occurs the prognosis is unfavorable without an 
operation ; but surgical interference presents good chances of 
recovery if not delayed until the occurrence of septicaemia, brain- 
abscess, sinus-thrombosis and phlebitis, or meningitis. Vulpius 
{Archives of Otology, April, 1895) reports three cases of in- 
fluenzal otitis, mastoiditis, and epidural suppuration cured by 
operations. 

Treatment. — If the patient is seen before perforation of 
the drum-head occurs, and signs of fluid in the middle ear are 
discovered, paracentesis should be performed at once, as de- 
scribed in treating of acute inflammation of the middle ear. 
The incision should be a long one, for its tendency is to close 
soon. A case to the point occurred while writing this. It 
became necessary to make an extensive opening in the drum- 
head and to incise the bulging posterior wall of the meatus, 
under ether, although a few days earlier a minute perforation 
was enlarged under cocaine. The first incision had closed, the 
discharge ceased, and great pain and sense of pressure ensued 
from the accumulated pus that was unable to escape. 

In acute inflammation the ice-bag (Fig. 78) should be 
applied without delay, and kept continuously in place until 
either the inflammation subsides or it becomes evident that an 
operation is imperative. The crushed ice must be replenished 
as fast as it melts. One or two days may be long enough, but 



DISEASES OF THE MASTOID PROCESS. 



147 



I have found it necessary at times to maintain constant cold for 
three or four consecutive days and nights. Sometimes an exac- 
erbation occurs and the ice must again be resorted to. This 
plan succeeds in some very serious cases, but if pus has formed 
cold may fail. For example : two children about 6 years old 
presented acute mastoiditis on the same day, and ice was applied 
alike to both. In five days one was discharged cured and the 
other developed a post-aural abscess, on opening which a fistula 
was found leading to the antrum. The ice-bag was powerless 
in the one case to avert a mastoid operation because destruction 
of osseous tissue had already taken place. 

Counter-irritation by mustard over the whole mastoid 
region, and along the course of 
the Eustachian tube when it is 
involved, often assists materially. 
It should be used nearly, but not 
quite, to the point of vesication, 
and then replaced by spirit of 
camphor on a flannel compress 
until the blush fades and the 
cutaneous irritation is again indi- 
cated. 

Leeches afford speedy relief 
during the acute, intense stage of 
the inflammation. They should 

be applied over the mastoid process near the auricle. Detailed 
directions for applying leeches will be found in the treatment of 
acute inflammation of the middle ear. General antiphlogistic 
treatment and anodynes are frequently called for, with laxatives- 
for the bowels, as described in the same chapter. 

If the application of the ice-bag is followed in a few days 
by subsidence of pain, fever, and the other symptoms, or if the 
cold is badly borne, it should be discontinued. If, in spite of 
all these antiphlogistic measures, the steady march of the 
destructive process is not stayed, an operation must not be too 
long delayed. A week or ten days may give time for extensive 
infiltration and invasion of the more vital organs. Nevertheless, 




Fig. 



-The Author's Aural, 
Ice-bag. 



148 DISEASES OF THE EAR, NOSE, AND THROAT. 

I have seen numerous instances in which very grave and alarm- 
ing symptoms have yielded to this palliative method of treat- 
ment, — cases in which excellent surgeons believed an operation 
to be inevitable. 

But it is a matter of duty to emphasize the possibility of a 
sudden fatal termination if the necessary operation is too long 
postponed. I have seen fatal results follow such delay and 
refusal to allow an operation, but I have never seen a fatal 
termination due to the operation itself. The disease is 
dangerous ; the operation is not, in the hands of a competent 
operator. If the mastoid hold necrotic tissue, the operation 
affords immediate relief. It gives free exit to the pent-up 
discharges and removes a threatening cause of disaster. 

Any well-informed physician, after some practice on the 
cadaver, can perform the simple operation with safety and suc- 
cess if he observe the rules laid down : but in order to have 



Fig. 79.— Buck's Mastoid Knife. 

well at command all the surgical relations of the parts con- 
cerned, the operation ought to be studied and performed several 
times on the cadaver. To illustrate : out of seventeen mastoid 
operations the author has made in one month, twelve were on 
cadavers and five only on patients. 

Wilde's incision, at least, should be made as soon as 
it becomes evident, by the presence of a fluctuating swelling 
back of the ear, that pus is present. Any one can do this with 
a sharp, strong bistoury (Fig. 79). The cut is made as nearly 
as possible in the line of the incision that may be required later 
for the mastoid operation, — about three-eighths of an inch (one 
centimetre) posterior to the insertion of the auricle and parallel 
with it. The incision is carried down to the bone, the pus evac- 
uated, and a fistula searched for with the strong probe. If none 
is present, and it is apparent that the abscess is subperiosteal, 
and no superficial caries of the bone needs curetting, the cavity 



DISEASES OF THE MASTOID PROCESS. 149 

is treated antiseptically, as will appear later, until pus formation 
ceases. Then it is allowed to close. 

Indications and Preparations for Mastoid Operations. 

Indications for Operating. — The following six rules, by 
which the perplexing question of when to operate is decided, 
were presented by the writer in a paper before the first Pan- 
American Medical Congress, and received the approval of 
the aural surgeons present, including Professor Politzer, with 
unanimity of opinion : — 

The mastoid process should be opened 

1. When there is acute inflammation of the bone that 
resists palliative treatment. 

2. When repeated swellings and abscesses occur. 

3. When there is a bulging of the posterior and superior 
wall of the meatus, with suppuration of the middle ear. 

4. When there is a fistula. 

5. When there are severe pains in the same side of the 
head as the diseased ear and resisting all other treatment. 

6. When a foul otorrhcea cannot be cured by any other 
means. 

These rules may be termed conservative, and whatever 
deviation we may indulge in ought to be at once favorable to 
the operation and the welfare of the patient. Too great tem- 
porizing favors sinus-thrombosis, septicaemia, brain-abscess, and 
meningitis. 

There are a few points in this connection worth mention- 
ing, for they are closely related to a successful issue. The best 
illumination is had by the use of a light reflected from the 
mirror on the operator's forehead, after the cortex is opened 
(Fig. 4). This affords a decided advantage over direct light. 
It is more intense, especially from the sixty-candle-power Wels- 
bach gas-burner (Fig. 5) ; it can be thrown into the opening of 
the bone in every direction, and there are no shadows to obscure 
the field. 

Preparation of the Patient. — The day preceding the oper- 
ation the patient's mastoid region, together with an area of three 



150 DISEASES OF THE EAR, NOSE, AND THROAT. 

inches in extent above and behind it, is shaved and washed with 
soap and warm water, then with ether, and finally with the 
bichloride solution (hydrargyrum bichloride), 1 to 1000. The 
meatus is syringed with the latter solution. The parts are then 
dressed with sublimated gauze and bandage. The bowels are 
relaxed the same evening, and beef-tea only is allowed on the 
day of the operation. Ether is preferable to chloroform on 
account of its greater safety. Only so much as is absolutely 



Fig. 80.— J. B. Hamilton's Scalpel. 

necessary to procure freedom from pain and movement is em- 
ployed, in order to avoid a subsequent bronchitis or pneumonia. 

The patient's clothing is removed from his shoulders and a 
blanket, covered with a rubber sheet, is substituted, so as to 
have the clothes clean when he is returned to bed. The hair, 
especially in the case of females, need not be entirely sacrificed, 
as is often done, but it is preserved in a cleanly condition by 
enveloping it in a sublimated cap or towel. 

The operator and assistants prepare by rolling the sleeves 




!«l!18li;«M«BB«»iaiMllll!lll!«!3J!iliiani!«!llil 



- -^I ~TMilg : : ~ *iamm 



Fig. 81.— Buck's Mastoid Chisels. 



above the elbows and vigorously scrubbing their forearms and 
hands and nails with brush, warm water, and soap. Rubber 
aprons and operating-gowns complete the surgeon's toilet. A 
table forty-two inches high is used by the writer in order to 
escape the necessity of a wearying, stooping position during the 
operation. 

The instruments, a quarter of an hour before they are 
needed, are steamed or boiled for five minutes in a 1-per-cent. 
soda solution, which does not corrode, and then they are placed 



DISEASES OF THE MASTOID PROCESS. 



151 






in warm, sterilized water. The scalpels are simply immersed in 
boiling water a moment. For many years the writer used a 5- 
per-cent. carbolic-acid solution for the instruments, instead of 
boiling, but a serious objection to this is that the operator's 
fingers are benumbed by the acid. 

The instruments required are a couple of strong, sharp 




jfiBBBBasa 



immmmmsmm* 



TRU«X CREENE fcCC 

Fig. 82.— The Author's Loxg Mastoid Gouges. Actual Width. 



scalpels (Fig. 80), four artery-forceps, a periosteum elevator, 
self-retaining retracting-hooks, several sizes of chisels (Fig. 81), 
three sizes of long gouges (Fig. 82), a metal mallet (Fig. 83), 
several sizes of curettes (Fig. 84), strong probes and forceps, a 




Fig. 83.— Lead-Filled Mallet. 



mastoid guide (Fig. 85), tongue-forceps (Fig. 86), and a syringe 
(Fig. 31) with hot water. 

The Periosteum Separator, Retractor, and Curette. 
This hoe-shaped device (Fig. 87) overcomes a serious objec- 
tion to the misnamed periosteotomes we have formerly used. 
Indeed, these instruments should not be u tomes " at all. They 



152 



DISEASES OF THE EAR, NOSE, AND THROAT. 



should not cut the membrane, but should lift it from the bone 
in continuity, so as to carefully preserve its integrity. 

The old periosteotomes put the operator at a disadvantage 



««w,.,„. 



Fig. 84.— The Author's Set of Curettes. 

by necessitating an unnatural play of his muscles. With a 
pushing motion one has not perfect control of the movements of 
the instrument and it is likely to slip and cut where it is not 




Fig. 85.— The Author's Mastoid Guide. 



desirable to wound. In the use of this kind of a lifter the mo- 
tion is one of drawing or pulling toward one's self; so that the 
muscles brought into play are, together with the instrument, 




Fig. 86.— Mathieu's Tongue-holding Forceps. 



under easy control, — on the same principle as the farmer's use 
of his hoe, after which it is patterned. 

As the separator serves the purpose not only of detaching 
the periosteum, but of retracting the loosened tissues, or of 



DISEASES OF THE MASTOID PROCESS. 



153 



curetting necrosed bone, it may be said to constitute three 
instruments in one. 

The double retractors (Fig. 88) take the place of an assist- 
ant in keeping the soft tissues out of the way of the operator 
and in controlling the haemorrhage during mastoid and other 
operations of like magnitude. The retractors consist of two 
shafts, each armed with a series of hooks that can be brought 






« 



Fig. 87.— The Author's Periosteum Separator. 



together and interlocked for insertion into the incision, when 
they can be separated and fixed at any desirable point up to two 
inches apart. After they have been drawn apart as far as may 
be required, the thumb-screw on the fixation-bar next to the 
hooks should be screwed down firmly into the bar, the handles 
should be pressed a little together until the tissues are well 
stretched as the distal ends of the retractors separate, then the 




Fig. 88.— The Author's Double Retractors. 



thumb-nut on the thread-bar should be turned down against 
the movable handle. 

If the instrument is properly adjusted the tissues cannot 
slip out of its jaws and their pressure on the stretched lips of 
the wound reduces the haemorrhage to a minimum. In some 
operations these hooks have proved more effective than five 
artery-forceps. 

The following arrangement renders these retractors equally 



154: DISEASES OF THE EAR, NOSE, AND THROAT. 

useful in the smallest and the largest mastoid operations : The 
outer half of the shaft of hooks can he slipped out of the inner 
half, leaving the retractors only an inch long. Replacing the 
adjustable series of hooks makes them two inches long, and by- 
drawing these adjustable hooks outward one-half inch you can 
lengthen the hooks to two and one-half inches. This has the 
effect, when the instrument is in position in a large wound, of 
making an opening two inches to three and one-half inches 
wide by three or more inches long, through which to work. 
However, the opening can be made as small as one wishes, and 
the capacity of the instrument is far beyond what we usually 
require in operations on the skull ; but I have had it made so 
as to be of service in other and more extensive operations, since 
its size in no way impairs its efficiency in mastoid cases. 

When the adjustable parts of the hooks are removed for 
small operations the openings in the permanent hook-shafts, into 
which the adjustable hooks fit, may be securely sealed by a 
bit of beeswax to prevent the entrance of blood, etc. After 
being used, this wax will run out on the application of a little 
heat. A drop of oil should then be put in the same openings 
to prevent corrosion or sticking of the adjustable shank. 

The straight-edged chisels are employed to open the firm 
cortex, but after the antrum or cells are reached the writer's 
long gouges are better adapted to the work. The length of the 
shaft allows the operator's hand to be sufficiently removed from 
the cavity to give an unobstructed field of vision. 

As we cannot know the extent of the pathological process 
before entering the bone, it does not appear to be advisable to 
decide in advance upon any special method of procedure save 
one : remove all dead and diseased tissue. Whatever method 
does this, does best. Stacke's and Bergmann's operations have 
the advantage of affording the greatest accessibility to the tym- 
panum ; so that if it is necessary to remove necrosed ossicles or 
diseased tympanic tissue it can be done with greater facility and 
thoroughness. 



CHAPTER XV. 

THE MASTOID OPERATIONS. 

For our purpose it is most convenient to treat of mastoid 
operations under three headings: (1) the simple mastoid opera- 
tion ; (2) the radical operation ; (3) the modified operation. 

The simple, or what has been known as the Schwartze op- 
eration is the one most commonly performed, and is adapted for 
primary mastoid abscess, or that condition in which it is neces- 
sary to penetrate the bone without entering the tympanic cavity. 

The radical operation, devised by Stacke, is much more 
extensive and complicated, and is intended to open not only the 
antrum, but to expose the whole tympanic cavity and to remove 
one or more of the ossicles and any diseased tissue that may be 
found in the middle ear. 

The modified operation is a convenient combination of the 
best principles governing the other two, more thorough than 
the first, and less menacing to important structures than the 
second. 

The Simple Mastoid Operation (Schwartze). 

All preparations having been made as already detailed, the 
ear cleansed, etc., the auricle is bent forward and the incision is 
made, beginning at the apex of the mastoid and extending 
upward and forward until within three-eighths of an inch (one 
centimetre) of the auricular attachment ; then it is carried par- 
allel to the auricle to a level with the superior attachment. 
The incision should be made from below upward, for if made 
in a downward direction it is possible for the knife to slip ofT 
from the rounding surface of the mastoid tip and plunge into 
the soft tissues of the neck, for one naturally bears hard upon 
the knife to cut to the bone. The posterior auricular artery or 
its anterior branch will have been severed and is caught up 
with the small artery- forceps and twisted. The forceps can be 
left holding it, instead of stopping to ligate. 

(155) 



156 



DISEASES OF THE EAR, NOSE, AND THROAT. 



The bleeding may be considerable for a few minutes, and if 
a pus-cavity is opened the contents usually gush out with con- 
siderable force. The haemorrhage is dried rapidly with small 
pieces of moist sublimated gauze, the assistant consuming as little 
time as possible. If necessary, several small artery-forceps can 
be used to arrest the venous flow, and they can be left in situ 
when the retractors are applied. The periosteal elevator (Fig. 







Fig. 91.— Hokizontal Section Through Right Temporal Bone, Cut Two Mil- 
limetres Above the Centre of the External Canal. (After C R. Holmes.) 

O, opening in mastoid leading to antrum ; the heavily-dotted lines indicate the depth 
to which the opening penetrated in the upper section of this bone ; small arrow indicates 
the relative position of the spina; ##, wedge between opening in mastoid and external 
meatus ; M, mastoid ; 23, dotted lines indicating how osteosclerosis may increase the 
depth to which it is necessary to penetrate; C, external canal ; *, large cell in direct 
communication with the floor of the antrum above ; L8, lateral sinus ; z, posterior semi- 
circular canal ; N, facial nerve ; x, horizontal semicircular canal ; 2, vestibule ; 1, internal 
canal ; 3, cochlea ; k, fenestra ovalis ; 10, Eustachian canal ; MT, membrana tympani. 



87) is now used to separate the periosteum backward far 
enough to expose all the surface covering the cellular part of 
the bone, and forward to the margin of the external meatus. 
The periosteum should be kept intact and carefully preserved. 
The self-retaining double hooks (Fig. 88) are then inserted into 
the wound, the teeth being interlocked and resting on the 
denuded bone. They are then separated as far as possible and 
fastened as previously described. In short incisions, as in chil- 




Fig. 89.— Side-view of a Skull, Showing {Hi) Opening in Mastoid Pkocess 
for Schwartze Operation. (Author's specimen.) 

The wavering black line just above 1 is the course of the facial nerve exposed ; above 
and at the left of this is seen the tympanic cavity; ii. opening by trephine to explore 
the roof of the middle ear: m lie over the course of the lateral sinus; iv, Reed's base- 
line ; v, trephined opening for cerebellar abscess. 




Fig. 90.— Schwartze Operation. (Author's specimen.) 

View of skull from below, showing tympanic cavity, looking from below upward and 
inward. The anteroinferior wall of the osseous meatus is removed, i, postero-superior 
wall of the meatus ; at the right of i is an opening into the mastoid cells: ii, opening 
above meatus for cerebral abscess ; Hi, Schwartze opening into antrum: v, opening for 
cerebellar abscess : 6, exit of facial nerve (black line running downward) : 7. stirrup in 
foramen ovale. The dark space just above the stirrup shows the opened Fallopian cauai. 



THE MASTOID OPERATIONS. 



157 



dren, the extra five hooks are not needed. The haemorrhage 
now practically ceases from the soft tissues because of the press- 



*-# 



A 



y 





>*d 






^ 


9 




1 


1$ 




M 




^4-^m 


m < 1 






* f k 

i_.n t"<: \ rrrn ; I i [ 



£Fig. 92.— Opening of the Antrum. (After C. R. Holmes.) 

W W and Y Y, horizontal and perpendicular planes of the skull ; O, opening: in mas- 
toid leading to antrum ; OA, antrum : LS, lateral sinus ; 31, mastoid process ; 22, poste- 
rior wall of external meatus ; 15, styloid process ; 31T, membrana tympani ; Ik, glenoid 
cavity ; 28, Glaserian fissure ; 17, zygomatic process ; 12 and 13, outlines of hammer and 
anvil and location of attic ; 16, spina supra meatus ; *, dotted lines showing position of 
antrum ; E, linea temporalis. 



ure and stretching by the hooks. If a fistula in the bone is 
found, it is enlarged ; if there is none, and the antrum is sought, 
the bone is opened on a level with the superior border of the 



158 



DISEASES OF THE EAR, NOSE, AND THROAT. 



external meatus and three-eighths of an inch (one centimetre) 
hack of its posterior wall (Figs. 89, 90, and 91). 

The mallet and straight-edged chisels are used to remove 
the cortex in preference to the trephine or drill. The broad 
chisel is best here. The strokes of the mallet must always be 
light enough to run no risk of forcing the chisel through 
softened bone into the vital parts. 

The general direction of the cone-shaped mass of bone to 




\zltxiz 



Fig. 93.— Horizontal Section Through Right Temporal, Bone, Showing 
Distance Between Lateral Sinus and External Canal. Cut Begins 
Below Centre of External Canal, Passing Obliquely Upward and 
Inward. (After C. R. Holmes.) 

LS, lateral sinus ; M, mastoid ; JY. facial nerve ; TC, tympanic cavity ; 2, vestibule ; 
MT, membrana tympani ; C, external canal ; small arrow indicates the point where a 
perpendicular line from the spina supra meatus would touch. 

be removed is inward, forward, and a little upward (Fig. 91); 
but one must always bear in mind that these terms are relative 
ones, for we speak as if the patient were in an upright, instead 
of a supine position. A good rule is to keep close to the meatus, 
follow its direction, and keep above it if the antrum is to be 
opened (Fig. 92). 

As soon as the cortex is removed the forehead-mirror (Fig. 
4) and brilliant illumination should be used (Fig. 5). If dead 
bone is reached there is little or no difficulty in distinguishing 



THE MASTOID OPERATIONS. 



159 



it from the healthy. It is softer, darker, crumbling, and is often 
filled with dark, fungus-like granulations as well as pus. It 
breaks down readily under the curette and should be entirely 
removed until nothing but healthy tissue is to be seen. 

The opening in the cortex should be made capacious enough 
to allow of easy inspection of all the interior of the process. In 
the adult the oval aperture should be about one-half by three- 
fourths of an inch in diameter or ten by twelve or fifteen milli- 
metres, with the long axis in the vertical. The surgeon should 



Zo 





a jg^ rc 




^^J^&>y mt 


\li 


mWm 


r^m 


f9@Ml# 


i < 




B 

x /^^m 




/ V i 


i^**-MP%\\ ^ 




ivJr^ v" 




f ■< m *- 


y 4r*~V~" v ^^^Hsai 


r. AT 0' 


&FgSR^g£S3L 


■v ^r a*i 


^ < ^3S2£i 


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Fig. 94.— Horizontal Section Through Right Temporal Bone. Cut Near- 
Centre of External Meatus, Showing How Close the Lateral Sinus 
May Come to the External Canal in Some Cases. (After C. R. Holmes.) 

a, internal carotid artery ; V, internal jugular vein. For explanation of other letters 
see Fig. 91. 



be satisfied with nothing but thoroughness of detail. If the 
carious bone extend to the dura or lateral sinus it is removed 
thus far, exercising great caution not to injure either, and, 
although it has often been necessary to expose both, I have 
never seen any ill results follow. If the lateral sinus should be 
accidentally opened, the haemorrhage will be profuse and will 
necessitate tamponing the cavity with iodoform gauze and post- 
poning further operative procedure for a fortnight. 

The variation in the distance between the external canal 
and the lateral sinus is shown in the same individual on the 



160 



DISEASES OF THE EAR, NOSE, AND THROAT. 



opposite sides of a skull in my possession (Figs. 77, 93, and 94). 
The surgical relations and close proximity of the lateral sinus, 
the facial nerve, and the semicircular canals are plainly visible 
in Figs. 91, 93, and 95 (LS, N, etc.). 

In many cases this simple operation suffices to effect a cure 
and it is not necessary to proceed farther. All projecting spiculse 
of bone are removed, rough corners rounded off, the wound is 







Fig. 95.— Perpendicular Section Through the Right Temporal Bone, 
Beginning at /Line BB, Behind Opening O, in Mastoid (Fig. 92), and 
Directed Inward and Forward, Cutting Eustachian Tube in its Long 
Axis. (After C. R. Holmes.) 

iV, dotted lines show the course of the facial and chorda tympani nerves; M, mas- 
toid ; Ch, chorda tympani nerve ; MT. membrana tympani ; a, canal for internal carotid ; 
10, Eustachian tube ; 9, processus cochliariformis ;~ At, attic ; 7 and 8, showing defects in 
the bone covering attic and antrum ; OA, opening into antrum (Fig. 92) ; LS, lateral 
sinus ; * antrum ; O, dotted lines indicating funnel-shaped opening (Fig. 92). 



syringed with quite warm bichloride solution, 1 to 1000, then 
dried and sprinkled with aristol (Fig. 32) or iodoform powder 
(Fig. 62). The upper section of the wound is stitched to a 
level with the upper border of the bone-opening only. The 
cavity is packed very lightly with iodoform gauze, covered thickly 
with absorbent cotton, and the dressing is completed with a net 
or crinoline bandage. These bandages are not to be applied 
very firmly, since the sizing they contain, being moistened before 




Fig. 96.— Adhesive-Pilaster Dressing for Mastoid Wound. (Author's case.) 



Fig. 97.— Lime of Incision Healed Two Months After a Schwartze Operation. 

(Author's case.) 



THE MASTOID OPERATIONS. 161 

applying, drys and contracts, setting somewhat like a plaster- 
of- Paris bandage. Later, an adhesive plaster can be substituted 
for the bandage (Fig. 96). The wound is kept sufficiently open 
to permit inspection and treatment until the cavity fills with 
healthy cicatricial tissue. 

The patient is now put to bed. If the temperature were 
high before the operation it usually falls, but it may remain 
near 100° F. for a few days. The dressing is not disturbed for 
four or five days unless considerable haemorrhage, discharge, 
odor, pain, or fever should call for it. Too frequent dressings 
and forcible irrigations retard new epithelial formation, while 
too infrequent dressings favor decomposition, septic infection, 
and exuberant granulations. I have usually made it a rule, 
even in this simple operation, to so connect the middle ear with 
the mastoid opening as to permit a current of water to pass into 
one and out of the other for the sake of absolute cleanliness. 

The duration of this operation, from the first incision to 
the completion of the operation and insufflation of the powder, 
has varied in my practice from fifteen to thirty-five minutes. 
With good assistants one can acquire dexterity of operation 
without incurring any risks, and the patients make a better re- 
covery than when narcosis is protracted. The length of time 
required for complete recovery varies greatly. I have had 
patients leave the hospital in a few days or a week and have 
found them cured at the expiration of the fourth week, while 
others, for various reasons, extend over three or four months. 
Six or eight weeks w r ould be a fair average time to give as nec- 
essary for a cure, and patients should be informed that it may 
require longer (Fig. 97). 

The Radical Mastoid Operation (Stacke). 
The first incision is the same as in the simple operation, 
except that it is carried above the insertion of the auricle and 
then forward as far as a point directly superior to the anterior 
wall of the meatus (Fig. 98). After the periosteum is raised to 
the mouth of the meatus the periosteal end of the mastoid 

guide (Fig. 85) is inserted between the posterior wall of the 

u 



162 



DISEASES OF THE EAR, NOSE, AND THROAT. 



osseous canal and its periosteal lining and the latter is raised 
as far as the membrana tympani. One can tell when the 
middle ear is readied, for at that instant resistance ceases. 
The instrument is carried no farther inward, but is moved care- 
fully around the whole circumference of the canal, separating 
the membranous lining and preserving its integrity. 

The integument is now drawn out of the canal like a 
severed glove-finger and reflected forward with the auricle so as 
to expose the bony canal and drum-head. The latter is now 







Fig. 98.— The Stacke Operation Completed. (After C. R. Holmes.) 

detached. The posterior canal-wall is chiseled away, backward 
into the antrum and inward as far as the tympanic attic (Fig. 
99), removing the wedge-shaped portion of bone constituting 
the outer boundry of the attic (Fig. 100, No. 4), until a bent 
probe, in contact with the attic-roof and drawn outward, meets 
no resistance. The whole inner wall of the tympanum is now 
exposed to view, and this cavity, the antrum, and the meatus 
are converted into one cavity. The anvil is detached from its 
articulation with the stirrup (Fig. 51) and removed with the 
pincette (Fig. 55) care being taken to not dislocate the 




Fig. 99.— Side of Skull, Showing Stacke Operation. (Author's specimen.) 

The postero-superior wall of the meatus is removed. The antrum is seen below 
8 and the oval window at the right of 9. Below the oval foramen is seen the round 
window, and the dark spot above and to the right of the 9 is an opening into the external 
semicircular canal. The projecting ridge between this and the oval window is the 
Fallopian, or facial, canal. 12, point for trephining to open the lateral sinus. 




Fig. 100.— Vertical Section Through the Ear. (Author's specimen.) 

4, wedge-shaped portion of bone forming outer boundary of tbe tympanic attic ; 
dotted line shows the section removed in the Stacke operation ; 5, dotted line shows 
course of facial nerve ; the bright spot in the dark area between U and 5 is the end of the 
probe, seen through the aditus ad antrum, resting in the antrum ; 6, remnant of the 
drum-head. 



THE MASTOID OPERATIONS. 163 

stirrup and thus open the vestibule. The drum-head is re- 
moved in its entirety together with the mallet. This is a 
simple maneuver under the present conditions. All carious 
or necrotic tissue, granulations, or cholesteatomata are curetted 
away (Fig. 75). 

When the membranous canal is returned to its place it is 
incised along the median line of the posterior wall, longitudin- 
ally, up to the concha, where an incision at right angles to the 
first is made through the posterior half of its circumference. 
The two flaps resulting are packed, — the one upward and back- 
ward and the lower downward and backward into the mastoid 
cavity. This gives access to one large cavity for after-treatment 
through the meatus. 

In this operation we have not only the lateral sinus and 
dura to avoid, but the facial nerve and semicircular canals. To 
escape wounding the facial nerve, as soon as we arrive in its 
vicinity the mastoid guide (Fig. 85) is inserted into the attic 
and the narrow toe of the foot-plate is passed through the aditus 
ad antrum and toward the latter cavity. The long handle is 
brought forward and downward over the cheek so that the end 
of the handle lies in a direct line with the lower border of the 
upper teeth or lip. Then the foot-plate falls over the Fallopian 
canal containing the nerve, and the chisel will strike the guide 
before it can reach the nerve. An assistant is instructed to 
hold the guide scrupulously in place and to give the warning 
instantly when it is touched. The facial canal is sometimes 
deficient or destroyed, leaving the nerve exposed. 

It is of the greatest importance to avoid injury of the facial 
nerve, as it produces a shocking deformity of the face (Fig. 70). 
I have seen facial paralysis produced, in my opinion, by packing 
the wound-cavity too firmly with the gauze, producing pressure 
on the exposed nerve. 

An anomalous position of the facial nerve renders it liable 
to injury if one chisels near the floor of the external canal. In 
using the middle-ear curette one should not forget that the 
tympanic walls are sometimes as thin as an egg-shell (Figs. 95 
and 101). The internal carotid artery and the internal jugular 



164 



DISEASES OF THE EAR, NOSE, AND THROAT. 



vein are sometimes very imperfectly protected and liable to be 
penetrated. As one proceeds upward and backward the ex- 
ternal and posterior semicircular canals must be avoided. 

The radical, or Stacke, operation consumes more time than 
the simple, or Schwartze, operation. The time varies with 
different operators from one to two hours. Longer time is 
required for healing also on account of the greater extent of 







Fig. 101.— Horizontal Section of Temporal Bone, Cut Near Floor op 
External Meatus. (After C. JR. Holmes.) 

a, canal for internal carotid ; TO, tympanic cavity ; Ml, membrana tympani ; V, 
bulbus of internal jugular vein ; iV, facial nerve ; \LS, lateral sinus; M, mastoid. 



wound surface. Fig. 102 shows progress six weeks after the 
Stacke operation. 

The Modified Mastoid Operation. 

In this operation the incision is the same as in the radical 
one (Fig. 98). I do not dissect out the whole integumentary 
canal, but separate only its postero-superior half from its bony 
wall and then depress it sufficiently to give easy access to the 




Fig. 102.— Six Weeks After Stacke Operation. (Author's case.) 

1, point to apply electric current to affect superior branches of the facial nerve ; 2, to 
affect inferior branches in treating facial paresis or paralysis. 




Fig. 



103.— Appearance Two Weeks After a Modified Operation. Healed 
Five Weeks After Operation. (Author's case.) 



THE MASTOID OPERATIONS. 165 

tympanic cavity. By this means one-half of the soft meatus is 
left undisturbed and the integrity of the integumentary canal is 
preserved. This method leaves a less extensive wound to heal, 
and it has afforded the most satisfactory results. The collapse 
of the canal can be prevented by a light packing of the mastoid 
wound and by packing the canal or inserting a firm-rubber 
tube. In other respects this method, which I have preferred 
for several years, corresponds to the Stacke operation. 

It is safer not to close the wound entirely until it has 
healed from the bottom. When the interior has rilled with 
cicatricial tissue up to the surface of the outer table it is safe to 
allow it to close. I have had good results after closing the 
wound completely at the time of the operation, but it is 
certainly not so safe a plan. 

The best dressing is one of dithymol diiodide (aristol) 
sprinkled over the wound surfaces, covering them entirely. 
Then iodoform gauze should be placed lightly in the mouth of 
that part of the wound chosen to remain open. It should not 
be packed down to the bottom of the wound so as to crowd 
any discharge inward, but it should extend just far enough 
inward to keep the cutaneous tissues from closing over the su- 
perficial opening in the bone until the deep wound is well. 
Dithymol diiodide has two excellent qualities : it is the best 
cicatrizant we possess, and it has the additional advantage of 
being to some extent an anaesthetic. While iodoform is irritant 
and toxic and boric acid sometimes produces pain, dithymol 
diiodide soothes without any ill effects. 

After stitching that part of the wound to be closed and 
dressing the open mouth for drainage, the whole is covered 
with iodoform gauze, absorbent cotton, and a net bandage. 
This bandage is made of the common white mosquito-cloth, 
which, as used in the Northern States, is sized with a prepara- 
tion of glue. The roll of bandage is dipped in water just 
before applying, until it is wet through. Then the water is 
squeezed out and the bandage is applied as usual. When it 
dries, the layers adhere together firmly, so as to retain their 
position for many days in succession without any attention. 



166 DISEASES OF THE EAR, NOSE, AND THROAT. 

This operation requires more time than Schwartze's and 
less than Stacke's, both to perform and for healing. Fig. 103 
shows progress two weeks after the modified Stacke operation. 
Three weeks after the operation taste was suddenly lost, but 
returned again. The exuberant granulations seen on the right 
border of the wound were repressed with silver-nitrate stick. 

Abscess of Neck from Middle Ear and Mastoid 
Suppuration. 

This is an occasional complication that requires operative 
interference. It arises from the purulent process penetrating 
the bone and burrowing beneath the superficial or deep layer 
of muscles. If it break through the inferior wall of the tym- 
panic cavity, the pus-channel may extend along underneath the 
deep layer of muscles even to the thoracic cavity. If it rupture 
through the anterior wall of the middle ear, a retropharyngeal 
abscess or a superficial cervical abscess may develop. When 
the pus breaks through the inferior surface of the mastoid proc- 
ess, it burrows under the sterno-mastoid muscle and forms a 
swelling on the side of the neck. At first the tumor is small, is 
generally located directly below the lobule of the auricle, is hard 
to the touch, and may give so little evidence of its presence that 
it may be overlooked. 

So slight are the symptoms at first that patients do not 
mention the neck trouble, and it is only by the habit of close 
observation that the surgeon himself does not let so serious a 
matter escape him. While no active symptoms referable to the 
neck-abscess may occur during the first few days, it often 
increases rapidly in size. The surrounding tissues become infil- 
trated ; the tumefaction extends over a larger surface ; the over- 
lying skin becomes tense and shiny to such a degree as to 
suggest erysipelas ; the movements of the neck become restricted 
and painful ; the temperature rises; the tongue becomes coated; 
headache, loss of appetite, and other febrile disturbances super- 
vene. Although fluctuation does not occur early, especially if 
the abscess is deep-seated, the diagnosis is promptly suggested 
by the presence of the suppuration above. 







B-: 










^■L *75**jJjJB ^^ ^^ >'. 










f y JB^I^^-tBafc f -'ri'Tw i 














w 


^ 












JM 


^IBV 







Fig. 104.— Post-mortem Section of Mastoid Process. (Author's specimen.) 

T, tip of process; 2, fistula below T leading into mastoid cells : 3, opening made by 
trepbine, probe resting in antrum ; 4, cotton in external meatus. 




Fig. 105.— Appearance Three Weeks After a Modified Stacke and 
an Operation for a Neck-abscess. 

The latter is healed and the former kept open until the wound-cavity filled with 
healthy tissue. Patient discharged cured fifty-five days after operation. 






THE MASTOID OPERATIONS. 167 

The only treatment is to open and evacuate the cavity and 
treat it antiseptically until pus formation ceases. Great care 
must be taken to avoid injury to the net-work of veins, arteries, 
and nerves in this region. For this reason it is best to open the 
abscess as far back as possible, and yet open in a dependent 
position. Further treatment should be on general surgical 
principles. 

Fig. 105 shows such a case three weeks after the modified 
Stacke operation and opening of the neck-abscess, the latter 
being entirely healed. A drainage-tube was inserted into the 
neck-opening and brought out through the mastoid wound. 



CHAPTER XVI. 

DISEASES OF THE INTERNAL EAR. 

As compared with affections of the middle ear, diseases of 
the labyrinth are rare, except as sequels of tympanic diseases. 
The methods of making a differential diagnosis between these 
two parts of the ear are sufficiently set forth in the section on 
hearing- tests. 

Hyperemia and Anaemia of the Labyrinth. 

Hyperemia may occur as a result of middle-ear inflamma- 
tion or some intra-cranial disease, or secondarily to a disturbance 
of the circulation in the blood-vessels of the neck, such as 
pressure on the large veins, or it may be due to certain 
medicines, — quinine, sodium salicylate, amyl-nitrite, etc. It 
sometimes complicates the fevers. 

Anaemia of the labyrinth may follow great haemorrhages, 
exhausting affections, and various anomalies of the circulation. 

The symptoms need not necessarily include impairment of 
hearing, but tinnitus and giddiness are the principal- manifes- 
tations. These conditions will be recognized as accompani- 
ments to the main diseases which give rise to them, and the 
diagnosis, prognosis, and treatment will be determined accord- 
ingly. If hyperaemia is due to active inflammation of the 
middle ear, the measures laid down in the section on that 
subject should be brought into requisition : cocaine, local bleed- 
ing, counter-irritation, catharsis, bromides, rest, the mastoid 
ice-bag (Fig. 78), etc. 

In anaemia of the labyrinth the primary condition that 
causes the anaemia will suggest the treatment. 

Inflammation of the Labyrinth (Otitis Interna.) 

Primary inflammation of the internal ear is of very rare 
occurrence ; but a disease of the surrounding structures, the 
middle ear, or mastoid may extend to the labyrinth. An intra- 
(168) 



DISEASES OF THE INTERNAL EAR. 169 

cranial lesion also may involve this organ. Predisposing causes 
are to be found in the loss of the stirrup, caries and necrosis of 
the inner wall of the tympanic cavity, etc., by means of which 
an entrance of bacteria and discharges is effected into the 
labyrinth. 

Cases of primary labyrinthitis have been reported by 
Agnew, Schwartze, Webster, and others. Occasionally cases 
are seen in which, after a severe cold or some other cause, or 
even without any discernible cause, sudden deafness of greater 
or less degree comes on, without traces of middle-ear disease. 
Giddiness usually accompanies such attacks. The dizziness 
may disappear, leaving a permanent deafness. In case this 
deafness is due to a serous exudation into the labyrinth, pro- 
ducing pressure on the terminal filaments of the auditory nerve, 
the loss of hearing may not be complete or permanent. Ab- 
sorption of the exudate may be followed by a clearing up of the 
subjective symptoms and deafness. 

Purulent inflammation is of more serious import, since it 
not only robs the sufferer of the power of hearing, but jeopar- 
dizes his life. Besides the predisposing causes mentioned above, 
it is sometimes a result of the eruptive fevers, diphtheria, 
mumps, variola, typhoid fever, or cerebral meningitis. The 
latter disease is simulated by the most active form of primary 
labyrinthitis. The two are easily mistaken for each other, the 
symptoms are so similar, but the duration of the labyrinthal 
affection is but a small fraction of the other. 

Panotitis, or inflammation of both middle and internal ears, 
is generally the result of scarlet fever or diphtheria, producing 
irreparable * deafness and for some time a staggering gait. A 
separate description of this disease is not necessary, since it is a 
combination of two already presented. 

The prognosis of inflammation of the labyrinth is unfavor- 
able. Some cases recover ; more do not. One such case, com- 
plicated with mastoiditis, recovered entirely after four months, 
without mastoidectomy, although I was in doubt for a time if 
further postponement of the operation were justifiable. Another 
became entirely deaf during meningitis at the age of 2 years. 



170 DISEASES OF THE EAR, NOSE, AND THROAT. 

During the sixth year she began to distinguish sounds. She 
lias improved under treatment, and has learned to talk without 
special instruction or lip-reading. I have met with a number 
of such instances ; yet it is safest to give a very guarded and 
conservative prognosis. 

Treatment. — Potassium iodide, pilocarpine, iodine oint- 
ments, etc. , have been used by Politzer, Moos, Gruber, and 
others. Of a 2-per-cent. solution of pilocarpine, 2 to 6 drops 
are injected into the forearm daily, in increasing doses. 
General antiphlogistic treatment must be resorted to in the 
acute stage, such as is detailed in the division on acute inflam- 
mation of the middle ear. In syphilitic infection the iodides 
and pilocarpine are indicated. In suppuration the methods 
given for middle-ear suppuration are applicable. 

HEMORRHAGE INTO THE LABYRINTH. 

Extravasation of blood into the labyrinth may take place 
as the result of the same diseases that induce inflammation. of 
this organ, as well as from atheromatous degeneration, fracture 
of the temporal bone, concussion, and necrosis. Resolution 
may take place by absorption, or an inflammatory process may 
be set up, with its train of consequences, or the clot may 
undergo organization. 

Meniere's Disease. 

Meniere first described a group of symptoms that char- 
acterized a case of effusion of blood into the labyrinth : deaf- 
ness, vertigo, and vomiting. This disease comes on suddenly, 
the patient falling as in an epileptic seizure and presenting an 
appearance, on regaining consciousness, similar to one coming 
out of an epileptic fit. In addition to the symptoms mentioned, 
there may be subjective noises and total deafness. After con- 
sciousness returns and vomiting ceases, the great deafness, dizzi- 
ness, and tinnitus remain. Walking with the eyes closed is 
difficult and the body may incline toward the diseased side. 
The mental faculties evince impairment. 

Diagnosis. — This is based on the suddenness of the attack ; 



DISEASES OF THE INTERNAL EAR. 171 

the extreme loss of hearing without previous serious disturbance 
of function ; the presence of a group of symptoms pointing, in 
unison, toward aural disease ; absence of disease of the con- 
ducting apparatus or of any other structure than the auditory 
nerve. 

The prognosis is unhappy. 

Treatment. — Rest in bed and perfect quiet are important. 
The bowels should be relaxed, the ice-bag applied to the mastoid, 
and a counter-irritant to the side and back of the neck. Po- 
tassium iodide in large doses and pilocarpine may be employed 
as directed for labyrinthitis. 

LEUCOCYTHiEMIC DEAFNESS. 

Patients suffering from leucocythaemia are sometimes subject 
to sudden and complete deafness and vertigo, and even facial 
paralysis. The ear, like all the other organs, is subject to 
hemorrhagic and exudative processes, although it is not as fre- 
quently implicated as the eye. Inflammation may follow, re- 
sulting in proliferation of connective tissue or bony growths. 

The treatment consists in measures for the general con- 
dition and the remedies recommended in Meniere's disease. 

Syphilis of the Labyrinth. 

Syphilitic lesions of the labyrinth are most likely to occur 
during the tertiary stage, but sometimes manifest themselves in 
the secondary period. The precise pathological changes in this 
disease are not yet clearly established. The symptoms are very 
similar to those characterizing Meniere's disease. In most cases 
subjective noises are added to the great deafness and dizziness. 
The affection is usually bilateral. Bone-conduction is di- 
minished or destroyed. The presence of syphilitic lesions in 
other parts of the body, or a history of a previous infection, 
combined with the symptoms referred to, clear up the diagnosis. 
Of all children with inherited syphilis, 10 per cent, have ear 
trouble (Hutchinson and Jackson). Others claim as high as 
33 per cent. The characteristic Hutchinson teeth should be 
looked for. 



172 DISEASES OF THE EAR, NOSE, AND THROAT. 

The prognosis is unfavorable. In recent affections and in 
young persons the prospects are more encouraging than in the 
severe types with age and a generally impoverished condition 
to combat. 

The treatment is the same as for constitutional syphilis, 
with the addition of pilocarpine injections, in 2-per-cent. solu- 
tion, of 4 to 12 drops in increasing daily doses (Politzer). Any 
improvement to be had from the pilocarpine should show within 
two weeks. I generally employ the mixed treatment, — mercury 
and potassium iodide combined. 

Max Toeplitz reports, in the New York Medical Journal, 
October 7, 1893, a case of aural syphilis in which " the laby- 
rinth was affected primarily in the course of a freshly-acquired 
case of syphilis. The aural affection began simultaneously with 
the appearance of roseola. 

" The special features of this case are as follow : 1. The 
affection of the labyrinth occurred after the appearance of 
pharyngeal patches and simultaneously with the appearance of 
roseola. 2. The aural lesion took place during the secondary 
stage without attacking the middle ear. 3. The diagnosis of 
syphilis was made from the ear. 

" The pathological changes produced by the syphilitic 
poison, which entered the lymphatic and blood- current of the 
labyrinth from the pharynx through the aqueduct and the blood- 
vessels, probably consisted in inflammatory alterations of the 
membranous portion, the periosteum and the surrounding lymph 
of the vestibule, and the first turn of the cochlea, with an in- 
crease of cellular elements and haemorrhages. All these changes 
disappeared after energetic antiluetic treatment." 

Diseases of the Auditory Nerve. 

The acoustic nerve may become the seat of various changes 
— hyperemia, hypertrophy, atrophy, secondary inflammation, 
and suppuration — through invasion from the contiguous intra- 
cranial or tympanic structures. It must be admitted that the 
present state of our knowledge of these pathological processes 
affords no basis for a promising system of treatment. 



diseases of the internal ear. 173 

Neuroses of the Perceptive Apparatus, 
hyperaudition. 

A .transitory increase in the intensity of the hearing-power 
affects some individuals. For this condition I propose the term 
" hyperaudition " as conforming to our system of nomenclature 
and as heing correctly and briefly expressive. This condition is 
a symptom of cerebral excitement or irritation, and may con- 
stitute a precursor of intra-cranial disease. 

hyperesthesia. 

Auditory hyperesthesia is an insufferable sensitiveness to 
sounds or noises. Highly-nervous individuals often present this 
anomaly, and it is an accompaniment of headaches and intra- 
cranial affections. It is often observed in sclerosis of the middle 
ear. The slamming of a door, the firing of a gun, etc., cause 
much more discomfort than in a state of health. 

paracusis. 

This is a false perception of pitch. The tone is heard by 
air-conduction generally higher than its true pitch, but may be 
heard lower. This may occur in one ear only, even when both 
are affected by sclerosis, and it is due to an altered tension of 
the transmitting mechanism. I have observed in such cases 
that certain tones only, and mostly the higher, were thus in- 
correctly perceived by one ear, both being similarly diseased, 
while all tones were correctly heard by bone-conduction. The 
apparent alteration in pitch varies in different individuals from 
one-quarter to one-half tone, or even one or two tones. This 
trouble unfits a musician for any but solo-playing. 

Double hearing has been observed in acute middle-ear 
inflammation. The tone w r as perceived as a primary, accom- 
panied or followed by a secondary, sound, the latter being in the 
nature of an echo. This may be due to hearing correctly with 
the normal ear and incorrectly with the other. 



174 DISEASES OF THE EAR, NOSE, AND THROAT. 

PARACUSIS WILLISII. 

This is hearing better in a noise, and is pathognomonic of 
sclerosis. It is undoubtedly due to the fact that, when pow- 
erful sound-waves set the ossicles in vibration, the lesser vi- 
brations are carried along with the greater to the perceptive 
organ. Once arrived at the latter point, the smaller waves are 
recognized with the larger (see chapter on sclerosis). 

SUBJECTIVE SOUNDS. 

These are sounds experienced by the patient as real, but 
existing only in his own consciousness. They are not always 
referred to the ears, but to other parts of the head : the region 
immediately above the ears, the occiput, and even the vertex. 
They are due to irritation of the auditory nerve and possibly 
of the hearing-centre. Occasionally they are so intense that 
the sufferer is led to believe them to be objective sounds and 
that his friends ought to hear them by placing their ears close to 
his. They may become so unendurable as to cause melancholia 
and loss of sleep and memory. Even in greatly-impaired hear- 
ing and total deafness patients have declared to me that they 
would not care whether the treatment benefited the hearing, if 
only the interminable head-noises could be stopped. 

It is sometimes imagined that insects have gained entrance 
into the ears, and the surgeon is importuned repeatedly to look 
for them, being assured that they must be found. One woman 
persisted in her declarations that there were crickets in her ears, 
for she could hear their constant chirping. Notwithstanding 
my examinations and statements to the contrary, she filled her 
ears with spirit of turpentine. 

Very susceptible individuals may have their minds unbal- 
anced by this harassing, unceasing din. I have seen instances 
in which subjective voices were heard, but they were hallucina- 
tions of hearing in persons of unsound mind. Whether the 
psychoses were attributable to the disease or whether the latter 
was merely a coincident could not be determined. The latter 
was probably true, and in such cases the tinnitus aggravated 
the mental aberration. Ear treatment may afford much relief 



DISEASES OF THE INTERNAL EAR. 175 

m such nervous affections by removing the excitant of hearing- 
hallucinations. 

There is a wide variation in the character of the subjective 
noises. Most people call it a ringing of high pitch. In others 
it is like the roaring of water, the sighing of the winds, the 
rumbling of wagons, crackling or explosive sounds, or sudden 
changes from the usual ringing to a loud breaking forth of a 
tone, as if a small bell had been struck a hard blow. The pitch 
of the ringing in one ear may be in unison with a fork of 2048 
vibrations, or the third C above middle C of the piano, while 
the pitch of the tinnitus of the other ear may be much lower 
and the sound of a different quality. 

The noises are increased during a combination of low ba- 
rometer with low thermometer, especially so when the air is 
very humid. Continuous cloudy or rainy weather and winds 
give rise to them. The same is true of quinine, sodium salicy- 
late, alcoholic beverages, excessive tobacco-smoking, loss of 
sleep, sneezing, coughing, much use of the voice, very cold 
drinks or food, and being in a damp, cold, moldy atmosphere, 
such as in basements. On the other hand, w 7 arm, sunshiny 
weather diminishes the noises. They are less observed or 
entirely suppressed in the presence of objective sounds like 
those of an orchestra, the noises of the street or cars, etc. 
Often patients cannot tell whether or not the noises are 
present when objective sounds can be heard. When tinnitus 
first appears it may be intermittent, but in advanced sclerosis 
it becomes interminable. A certain tolerance of the noises is 
frequently acquired, so that they are not very much noticed 
when the individual is preoccupied or in a noisy locality ; 
but in quiet surroundings the noises seem to besiege the brain 
again with redoubled intensity. 

Nervous tinnitus is an affection in which the ear is not in- 
volved. It may arise from reflex causes and requires general, 
rather than special, treatment. However, the ear should be 
inspected for any possible lesion. 

Spasmodic noises, or those occasioned by spasmodic con- 
tractions of the muscles of the ear, are rare. In one case I could 



176 DISEASES OF THE EAR, NOSE, AND THROAT. 

plainly see, synchronously with the clicking noises, a rhythmical 
movement of the drum-head, — excursions inward and outward, 
— undoubtedly occasioned by spasmodic contractions of the ten- 
sor tympani muscle. Spasmodic contractions of the Eustachian 
tubal muscles may cause snapping sounds. Mucous rales occur 
in the middle ear in the same manner as they do in the bronch- 
ial tubes. Circulatory disturbances of the heart, the internal 
carotid, or the arteries of the ear give rise to pulsating sounds 
in unison with the pulse. 

Prognosis. — This depends principally upon the cause, but, 
excepting in sclerosis and diseases of the labyrinth and of the 
brain, the prospect of relief is good. The longer the noises have 
existed, and the more unvarying and continuous their character, 
the less promising is the prognosis. 

Treatment. — Since tinnitus aurium is a symptom of various 
pathological processes, we can speak of its treatment here in a 
general way only, otherwise it would involve the measures 
necessary for the special treatment of all the causative conditions. 
These will be found in their proper divisions of the subject. 

It is much more difficult to stop the noises than to improve 
the hearing. The latter often increases, while the noises prove 
intractable. We may diminish the noises or change their char- 
acter, while we cannot by any known means eradicate them, in 
many cases. It is unwise to promise to cure or even to dimin- 
ish them. In the majority of instances the tinnitus is a symp- 
tom of sclerosis. In addition to the treatment outlined for 
sclerosis I have used counter-irritation with mustard or its oil, 
and have vesicated with cantharidal collodion. These applica- 
tions sometimes produce a beneficial effect. When the tinnitus 
has continued after an acute inflammation of the middle ear 
has subsided, I have found medium doses of sodium bromide 
afford complete relief. I attributed this to its sedative effect 
on the labyrinthal irritation. Charcot and Guye have recom- 
mended quinine. It may prove serviceable in periodical tin- 
nitus, but as it produces congestion of the middle ear and laby- 
rinth, and, in large or continued doses, deafness, its utility in 
ear affections is very limited. 






diseases of the internal ear. 177 

Paresis and Paralysis. 

There are certain forms of paresis and paralysis of the au- 
ditory nerve that are so rarely met with as to merit only a pass- 
ing notice in a work of such practical brevity as this. In some 
hysterical subjects anomalies of hearing and subjective noises 
occur, but in association with anaesthesia or hyperesthesia of 
other parts of the body that indicate the character of 
the affection. These attacks are transitory and without 
apparent changes in that part of the ear that is accessible to 
inspection. 

Treatment of these aberrations is largely based on the as- 
sociated causative conditions ; but, in addition to the general 
treatment, special measures may be employed by means of the 
ear-electrodes (Fig. 72). I have generally preferred the primary 
current of a faradic battery to the galvanic, for the former unites 
the properties of both currents, as I have shown in my batteries 
by means of the galvanometer. The negative pole is connected 
with the electrode that rests in the ear which requires stimula- 
tion or irritation. The current is turned on very mildly at first 
and gradually strengthened until it is as strong as can be com- 
fortably borne, and continued for six to ten minutes. By means 
of the author's electrodes the current is more limited to the ear 
than with the older kinds, which diffuse the current mostly over 
the side of the head. 

In using these electrodes it is not necessary to fill the 
meatus with water, as was the former custom, to the detri- 
ment of the drum-membrane, but the tips of the electrodes 
are moistened and covered with a wet layer of absorbent 
cotton. 

In treating paresis or paralysis of the facial nerve after a 
mastoid operation the wound can be filled with wet cotton and 
the electrode placed in contact with it. This conducts the 
current to the injured nerve. The other electrode is held in 
contact with the opposite mastoid process. During a part of 
the treatment the electrode is removed from the opposite ear 
and applied to the groups of muscles affected (Fig. 102). 

12 



178 diseases of the ear, nose, and throat. 

Cerebral Causes of Deafness. 

Cerebral deafness may arise in two ways : by a disease of 
the hearing-centres or by an extension of a disease of the brain 
or the meninges to the origin or course of the acoustic nerve 
or to the labyrinth. The most frequent cause of intra-cranial 
deafness is meningitis. The loss of hearing may not become 
apparent at the time that it occurs, but will be discovered when 
the patient regains consciousness. The destruction of hearing 
takes place within the first few weeks of the disease. This 
form of deafness is not amenable to treatment, the reason for 
which is apparent when we consider the pathological processes 
that destroy the function of the nerve : " Softening or thicken- 
ing of the ependyma of the fourth ventricle, purulent infiltration 
and softening of the auditory nerve" (Knapp), "imbedding of 
the latter in meningeal exudation" (Schwartze), "shriveling of 
the nerve-stem, and purulent inflammation of the membranous 
labyrinth, the origin of which can be traced to transmission of 
the inflammation either along the sheath of the auditory nerve 
(neuritis descendens) or through the aqueducts" (Politzer). 

The majority of cases of deaf-mutes coming under my ob- 
servation in which the deafness was acquired, were the result of 
meningitis. Politzer and Moos observed a staggering gait in 
half or more of their cases. Such has not been my experience, 
but it may be accounted for by the fact that my cases have not, 
as a rule, come under observation until the period of vertigo 
has passed, for this lasts only three or four months. 

I have not been able to verify the statement that tinnitus is 
a frequent symptom, but most of my cases have been children, 
and they rarely speak of subjective noises. 

Treatment will be considered only briefly, for its effects 
are usually nil. If the patient is seen during the meningitis, 
the ice-bag (Fig. 78) should be applied over the ear as soon as 
there are aural symptoms. Later, if the deafness is not of too 
long standing, absorbents and alteratives can be tried, such as 
potassium iodide and pilocarpine. 

Many pathological processes in the brain are capable of 
disturbing the hearing. It has been repeatedly seen that a dis- 



DISEASES OF THE INTERNAL EAR. 179 

ease of the left temporal lobe, involving the first convolution, 
produces word-deafness. In this peculiar state there is a hear- 
ing for sounds, but incapacity for interpreting the compound 
sounds entering into the formation of words. This circum- 
stance would tend to locate the cortical centre for hearing in 
this part of the brain. 

The most frequent cerebral cause of deafness is the 
presence of tumors. The symptoms are very like those of 
labyrinthal disease : dizziness, tinnitus, varying degrees of 
deafness, and gastric disturbances. 

The diagnosis is often impossible. In the case of tumor, 
however, facial paralysis may develop, and bone-conduction may 
not be obliterated as it is in the labyrinthal deafness. Tumors 
may also produce pressure affecting other nerves than the 
acoustic or facial. Anaesthesia of the skin of the corresponding 
side of the head is sometimes found. Symptoms pointing to 
involvement of the optic or other nerves may aid in arriving at 
a correct deduction. 

New Growths of the Internal Ear. 

New growths of primary formation in the internal ear have 
been met with but very infrequently, and clinically their con- 
sideration merits only brief mention. The presence of growths 
in this situation is usually due to an extension from the cranial 
or tympanic cavity of epithelioma or sarcoma. 



CHAPTER XVII. 
DISEASES OF THE INTERNAL EAR, CONCLUDED. 

Injuries of the Labyrinth. 

Penetrating wounds of the labyrinth are of infrequent 
occurrence, but more often damage is done by fractures of the 
temporal bone, and concussion transmitted through the bones or 
through the air and conducting apparatus to the labyrinth. 

The symptoms of fracture of the bone are : a flow of blood 
and serous fluid from the ear, inco-ordination, deafness, and 
vertigo. The symptoms of concussion are the same, with the 
exception of the bloody and serous discharges. I have seen 
quite a number of instances in which the symptoms of irritation 
or paralysis of the auditory nerve supervened upon blows on 
the skull or on the ear. In the latter, rupture of the drum- 
head generally was present when the cases were seen early, and 
in such instances the labyrinthal symptoms were not as severe 
as when the drum-head was not ruptured, for in the latter case 
the force of the concussion was spent mostly on the stirrup, 
probably impacting it into the oval window. I have examined 
many soldiers of the war between the States, who suffered more 
or less loss of hearing from concussions produced by cannons, 
exploding shells, etc., in battle. Instances have also come under 
my observation in which blows on the head from the " sand- 
bags " of robbers, and from other weapons, and concussions 
from falls, have produced total deafness. Many workers in 
boiler-shops have appeared at the clinics with great dullness of 
hearing and tinnitus. Their ears were generally full of hardened, 
impacted plugs of black wax. After removing these the 
impairment of hearing still remained of high degree. Black- 
smiths, tinsmiths, coopers, and iron-workers suffer similarly. 
This is due to the constant concussions of the drum-head, 
ossicles, and intra-labyrinthal fluid and the auditory nerve 
from their incessant hammerings. The effect is to produce, in 
(180) 



DISEASES OF THE INTERNAL EAR. 181 

addition to the labyrinthal affection, the sclerotic form of 
middle-ear catarrh, the treatment of which has already been 
given. 

The treatment for these forms of disturbances of hearing, 
of co-ordination, etc., is generally of little or no avail if several 
months or years have elapsed since the injury. In the early 
stage succeeding the concussion, the treatment laid down for 
tinnitus aurium and for paralysis of the acoustic nerve is indi- 
cated. 

Deaf-mutism. 

This is the lack or loss of speech due to congenital or 
acquired deafness. In my experience it is a rare condition. 
Only J of 1 per cent, of all the cases of ear defects that I 
have studied in hospital, dispensary, and private practice are of 
the deaf-mute class. 

Pathology. — In congenital deaf-mutism the precise con- 
dition to which it is due cannot be determined. This subject 
presents an opportunity for the application of the theory of re- 
version as affecting types of degeneracy. It may be owing to 
lack of development in some part of the organ of hearing, de- 
formities of the fenestra of the labyrinth, hydrocephalus, or 
pathological changes in the course or origin of the acoustic 
nerve. The acquired form may be due to middle-ear sclerosis, 
necrosis of the labyrinth, auditory neuritis, meningitis, or cere- 
britis. The tympanic and labyrinthal cavities may be entirely 
obliterated by connective-tissue and osseous proliferation. If 
the hearing is lost under the fifth year there is no speech, 
because it has not been acquired, while speech which has already 
been acquired later in life may be more or less perfectly retained 
after hearing is lost. However, I have many times observed 
that even in deaf-mute infants the primitive words "mamma" 
and " papa " only are uttered. 

I have seen dumbness follow the loss of hearing even after 
speech was acquired. The ability to articulate words grad- 
ually declined until nothing more than mumbling and mouthing 
of unintelligible sounds remained. In about 50 per cent, of 



1S2 DISEASES OF THE EAR, NOSE, AND THROAT. 






deaf-mutes the semicircular canals are affected, which accounts 
for their peculiar, straddling gait, the feet being kept wide apart, 
and for their inability to stand with their eyes closed, and 
especially on one foot. 

Etiology. — Congenital deaf-mutism may be due to heredity, 
but it is not a frequent occurrence. A constitutional predispo- 
sition to this defect exists in some families, several members of 
which are afflicted. In one family the healthy parents had five 
daughters with normal senses and six sons who were born deaf 
(Kramer). Among all the deaf-mutes I have examined I do 
not know of one whose parents were deaf-mutes, although some 
have had various middle-ear affections. Consanguineous mar- 
riages are believed to account for deaf-mutism in quite a large 
proportion of instances, as well as specific disease and intra- 
uterine influences. The acquired form may follow injuries 
during childbirth or infancy, meningitis, scarlatina, typhoid, 
diphtheria, mumps, syphilis, or inflammation of the labyrinth. 
I have not seen the epidemic influenza, or grip, given as a cause. 
I have had recently under treatment the case of a girl, 6 years 
of age, who had lost her hearing entirely for four years in con- 
sequence of an attack of the grip. Under treatment the hearing 
has returned sufficiently at the present time to enable her to 
hear moderately-loud conversation and to learn to speak many 
words intelligibly and to form them into sentences. Inspection 
revealed no change in the drum. 

Symptomatology . — In infants the defect is not likely to 
be discovered until about the time that children begin to talk, 
and even then it may be overlooked by the parents, who attrib- 
ute the backwardness to slow development. I have often 
observed that parents believed their children could hear and 
that some defect in the organs of speech accounted for its 
absence, and yet they were born deaf-mutes. Failure to respond 
to sounds and calls can be easily detected if tests are made in 
such a manner as not to attract the child's attention by move- 
ments within the range of vision. Calling its name from 
behind, clapping the hands in such a position as not to produce 
waves of air that will strike the child, and out of its sight, the 



DISEASES OF THE INTERNAL EAR. 183 

tuning-fork (Fig. 13), the Delstanche whistle, etc., are conclu- 
sive. If the child hear vowel or other sounds, a change of 
expression, a lighting up of the countenance, smiles, etc., evince 
the fact. 

Diagnosis. — The means of diagnosis have been indicated 
above. In a large proportion of cases a modicum of hearing is 
present. The ability to say " mamma " is not significant, since 
it is frequently present in hopeless cases. Such sounds are 
primordial and are uttered by the lower animals. 

While I have seen apparent improvement in a few cases of 
congenital deaf-mutes, it has not been of such a degree as to 
admit of understanding the common conversational tone. Loud 
sounds and some words could be appreciated, without doubt, but 
even this slight gift proved a pitiful source of happiness. A 
few cases are on record in which there was a useful development 
of the hearing after about the sixth year or after puberty. The 
acquired form is less promising still. 

Treatment. — In many cases examined by me there were 
evidences of middle-ear dry catarrh, but whether this bore any 
significant relation to the absence of hearing-power was a 
debatable question. It is possible that middle-ear disease in 
early infantile life may have involved the labyrinth in a 
destructive inflammatory process ; or, if the labyrinth has 
escaped, connective- tissue proliferation or osseous growths may 
have obliterated the round window or may have anchored the 
stirrup in the oval window so firmly as to preclude the possi- 
bility of its vibratory movements in response to sound-waves. 
If the auditory nerve is not destroyed, bone-conduction of sound 
can be demonstrated. In that case inflation of the middle ear 
and the application of the massage otoscope (Fig. 8), together 
with the galvano-faradic current (Fig. 72), may demonstrate the 
possibility of improvement after a few weeks. In one case of a 
young man with greatly-thickened and retracted drum-heads, I 
resected parts of them, which resulted in a considerable improve- 
ment. He had already been able to perceive the sounds of the 
vowels, and after the operations he acquired the use of quite a 
number of words before leaving the city. 



184 DISEASES OF THE EAR, NOSE, AND THROAT. 

Instruction of deaf-mutes should begin as soon as it is 
shown that there is no hope for the hearing. The younger the 
pupil, the greater the accomplishment in the schooling. During 
the World's Fair in Chicago great proficiency was shown in the 
attainments of very young children in lip-reading and articulate 
language in the school-exhibits of those who had never heard. 
The perfect discipline was something to be appreciated by those 
who have had much experience with the deaf-mute class. 
Indeed, I have often been led to a correct diagnosis in deaf-mute 
children before an examination was made, and before any in- 
formation was imparted, by their irritable temper and incoherent 
violent actions. Lip-reading and articulate speech should 
always be taught them, if possible, and the sign-language 
should be made only an accessory. Some children do, not 
acquire the former ; so the latter must be employed. The 
admirable schools for the deaf in Chicago and other large cities 
go further and impart a useful education and more or less 
manual training in order to render their graduates self-sup- 
porting. 

The education of the deaf should be no more neglected 
than that of the better favored of our race. Indeed, greater 
facilities should be afforded for the acquisition of an education 
and the acquirement of the prerequisites of good and useful 
citizenship, to counterbalance the unfortunate disadvantage at 
which they have been placed through no fault of their own. 
The means already enumerated are efficient. They are pro- 
vided by private and public schools in the cities, and by the 
States in their deaf-and-dumb asylums. The subjects are 
usually intelligent and quick-witted, and their proper care and 
training will insure adequate returns upon the investment from 
both economic and humanitarian considerations. 

Hearing-instruments. 

Of all the various devices for aiding the hearing two only 
have proven of actual practical value in my experience. They 
are the conical conversation-tube (Fig. 106) and the London 
horn (Fig. 107). The conversation-tube consists of a trumpet- 



DISEASES OF THE INTERNAL EAR. 185 

shaped mouth-piece to collect the sound-waves, connected with 
an ear-piece — both being of hard rubber — by a conical, elastic, 
spiral-wire tube covered with rubber and woven silk. The 
mouth-piece is placed close to the lips of the speaker, when a 
low, conversational tone can be employed, enabling the listener 




Fig. 106.— The Conical, Conversation-tubb. 

to hear words that are inaudible to others. The speaker should 
never talk loudly or cough or clear his throat with the mouth- 
piece near his lips, for often the hypersensitiveness of the 
affected ear renders these harsh, explosive sounds painful and 
irritating. These tubes are generally worn about the neck, 
under the coat, or rolled up in the coat-pocket. For near con- 
versation they are, by far, superior to any other device. 




Fig. 107.— The London Horn. 



The London horn (Fig. 107) is an excellent instrument for 
use at long distances, as in the cTfurch or lecture-room. It is 
made in three sizes and painted a dead-black preferably. The 
nickel-plated instruments are far more conspicuous. The horn 
is applied to the ear as in the case of the tube, and the large, 



186 DISEASES OF THE EAR, NOSE, AND THROAT. 

open end is directed toward the source of sound. There is one 
serious objection to the metal horns : they convey a metallic, 
adventitious sound along with the speaker's voice. This defect 
is especially noticeable in listening to singing and the playing of 
an orchestra. However, it is preferred to the tube by many. 
The most distinguished of American newspaper editors is 
entirely dependent upon it, and cannot be prevailed upon to 
try the tube. 

After an extensive destruction of the drum-head the hear- 
ing is sometimes much improved by placing a pledget of cotton 
lightly against the handle of the mallet. Sound-waves striking 
this are then communicated to the ossicles and so transmitted to 
the perceptive apparatus. In such cases the artificial ear-drum, 
consisting of a thin disc of soft rubber (TurnbulPs), is inserted 
into the meatus and nicely adjusted to the exposed mallet. 

The audiphone, consisting of a fan-shaped disc of vulcan- 
ized rubber, bent by a silken cord into a convex surface to -be 
presented toward the source of sound, the edge in contact with 
the upper teeth, has been used to some extent. I have tested 
it with numerous patients, but with few exceptions it was of 
little value. 

The rubber discs, apparitor auris, cornets, auricles, cones, 
etc. , made of soft rubber and advertised extensively in the 
newspapers, are generally of no use to patients, and are pro- 
vocative of irritation, inflammation, and even ulceration of the 
canal and tympanic membrane and cavity. Occasionally I have 
been told by the wearers that their hearing was better while 
these devices were in their ears. I have frequently found them 
in contact with the drum-head, bathed in decomposing pus. 

No efficient and harmless hearing instrument for wearing 
in the ear has yet been devised. Fame and fortune await the 
inventor of the aural equivalent of spectacles. 



PART II. 

Diseases of the Nose 



Plate 1. 




VERTICAL ANTFRO -POSTERIOR SECTION OF THE 
NASAL CAVITIES, MOUTH, PHARYNX AND LARYNX. 



^. S a jo us, Pmxr 



_Burk&M c Fetr,dge, Lith Phi la 



CHAPTER XVIII. 



EXAMINATION AND INSTRUMENTS. 



Rhinological practice requires an illuminating apparatus 
like the one shown in Fig. 5, or the electric forehead-lamp, or a 
student-lamp. Fig. 108 shows an electric light attachable to 
a portable battery. It consists of a cylinder, telescoping, from 
one and one-half to two inches (four to five centimetres) long, 
and is five-eighths of an inch (sixteen millimetres) in diameter, 




Fig. 108.— Electric Illuminator. 



provided with two powerful lenses. This instrument, when 
lighted, throws a white light of six- to eight- candle power 
directly upon the object in the focus. This instrument is par- 
ticularly adapted to the wants of the specialist. By removing 
it from the head-band it may be used as a hand-illuminator in 
examining other cavities of the body. The examiner should sit 
at the side of the patient, immediately in front and facing him, 
using the forehead-mirror, as shown in Fig. 4. Reflected light 
onlv can be used to advantage in this practice. The surgeon 

(189) 



190 



DISEASES OF THE EAR, NOSE, AND THROAT. 



should wear the mirror over his eye so as to look through the 
perforation in the mirror, and in such a manner as to shade 
both eyes from the light. The room is best darkened in order 
to avoid the contracting effect of the light on the pupils of the 
surgeon's eyes. 

During the examination of the nose, one hand of the oper- 




Fig. 109.— Ingals' Nasal Speculum. 



ator should rest on the top of the patient's head so as to control 
and manipulate its movements as is necessary in order to bring 
all the parts to be examined into the field of vision. 

The instruments required for anterior rhinoscopy are a 
nasal speculum (Fig. 109), a cotton-carrier (Fig. 9) to remove 
secretions that obstruct a view of the parts, and a bent probe 
for searching out hypersesthetic areas and determining the 
contour and extent of anomalies. 




Fig. 110.— The Author's Nasal Speculum. 

Ingals' speculum is best held in the palm of the hand with 
the back of the latter directed toward the patient's chin. The 
handle of the speculum should project straight downward and 
outward from the bivalves, so as to leave sufficient room between 
the patient's chin and the surgeon's hand. The valves should 
be small enough at their tip to use with children. In manipu- 



EXAMINATION AND INSTRUMENTS. 191 

lating the speculum the pressure ought to be exerted mainly on 
the soft, yielding ala of the nose, and not on the septum. The 
author's speculum (Fig. 110) is convenient for use in operations 
in the nose. It is held expanded by a thumb-screw. DeVilbiss 
also has devised an excellent self- retaining nostril-dilator to be 
held in place by a rubber band about the head. 

Anterior rhinoscopy, or the examination of the anterior 
n ares, reveals the anterior extremities of the turbinated bodies 
and the side of the septum. The patient's head is tilted back- 
ward or forward as the upper or lower parts of the nasal cavi- 
ties are to be inspected. In many instances we can obtain a 
clear view entirely through the naris to the vault and posterior 




Fig. 111.— Bos-worth's Tongue-depressor. 

wall of the pharynx. In others, hypertrophies of the turbinated 
bodies or of the septum or deflections of the latter occlude the 
view. 

In health the color of the mucous membrane covering the 
lower portions of the naris is a light pink ; that of the superior 
turbinated body and roof of the nasal arch is yellowish. The 
nature of the light furnishing the illumination may vary the 
shade considerably. 

Posterior rhinoscopy calls for the use of a tongue-depressor 
(Fig. Ill), rhinoscopic mirrors (Fig. 112), and occasionally a 
palate-retractor (Fig. 113). The tongue-depressor should not be 
inserted far enough to cause retching, and the patient is told not 
to resist the gentle pressure and not to gag. His co-operation 



192 



DISEASES OF THE EAR, NOSE, AND THROAT. 



aids materially in the examination, and only a little practice is 
necessary to success. When the rhinoscopic mirror is intro- 
duced, the tongue-depressor is held by the left hand and the 
mirror by the right. Just before introducing the mirror it is 
warmed by passing the glass side over the lamp for an instant 
only, to avoid the condensation of the patient's breath on it, 





Fig. 112.— Rhinoscopic Mirrors. 



which would prevent a reflection of the post-nasal image. If 
the mirrror is too greatly heated its backing is destroyed. 

With the light reflected into the throat by the forehead- 
mirror, the nasal mirror is carried over the depressed tongue 
until it nearly, but not quite, touches the posterior pharyngeal 
wall with the mirror-surface directed upward and forward (Fig. 
114). The natural inclination is to breathe through the mouth 
when it is open, and the patient is directed to breathe through 
his nose so that the soft palate will fall forward and downward 







Fig. 113.— White's Palate-retractor. 



from contact with the post-pharyngeal wall. Then, with the 
light properly directed upon the mirror, an image of the posterior 
naris should be seen. If the palate still embarrass the view, it 
can be lifted and drawn slightly forward by the palate-elevator 
(Figs. 113 and 115). Painting the uvula and velum with a 4- 
per-cent. solution of cocaine will facilitate this procedure. The 
rubber elevator is convenient. It is placed so as to lift the uvula 



EXAMINATION AND INSTRUMENTS. 



193 



with the palate, and the handle is held a little to one side, so 
as not to obstruct the field of vision. 



',, 



<£*■■ 




Fig. 114.— The Rhinoscopic Ibiage. (After Bosworth.) 

As large a mirror should be used as the space will permit 
(one-half to three-fourths of an inch — thirteen to nineteen mil- 
limetres), but it must be so small as not to necessarily come in 




Fig. 115.— Hard-Rubber Palate-elevator. 



contact with the surrounding parts and produce gagging. The 
mirror is so manipulated as to bring the plane of its surface at 



13 



194 



DISEASES OF THE EAR, NOSE, AND THROAT. 



„ f 



about an angle of sixty degrees to the perpendicular plane 
the posterior nares, in order to obtain a perfect image. 

The first reflected image to attract the attention is that of 
the velum palati. By slightly changing the position of the 
mirror, the septum on the one side and the orifice of the Eusta- 




DAVIDSON RUBBER Co. 

Fig. 116.— The Davidson Sprays. 



chian tube on the other come prominently into view, with the 
posterior ends of the turbinated bodies in the centre of the field. 
The two lower ones, of a light-pink hue, are easily distin- 
guished ; but the superior body, yellowish and dimly outlined 
in its remote recess, is not so easily seen. 




Fig. 117.— The DeVilbiss Universal Spray. 

The vault of the pharynx is rendered visible by tilting up- 
ward the mirror-handle in varying degrees until one obtains an 
image of the pharyngeal tonsil. 

The Davidson atomizers (Fig. 116) are very convenient for 
cleansing and medicating the nares. They throw a very coarse 



EXAMINATION AND INSTRUMENTS. 195 

spray, bathing the parts profusely. They hold a large amount 
of fluid, do not leak, and are supplied with curved tips for the 
naso-pharynx and larynx. The DeVilbiss atomizer (Fig. 117) 
has the best adjustable tip. It can be turned so as to throw the 
spray in any direction desired, from the posterior nares to the 
larynx. The latest device to be used with compressed air has a 
flange upon which the fingers rest to prevent the column of air 
from throwing the instrument out of the grasp. It is also made 
with a broad base so as to prevent it from tipping over upon 
the table. It can be used with the hand-bulb also, but the 
dilators and Davidson atomizer cannot, since they require more 
pressure. The lavolin atomizers (Figs. 118 and 119) are very 



i 




Fig. US.— The Lavolin Atomizer. 



convenient for home treatment. I often prescribe these with 
a 3-per-cent. solution of camphor-menthol for patients to use at 
bed-time, to aid in the treatment. By this means they keep the 
upper respiratory passages cleansed and protected and they are 
more faithful to the treatment. The results are more satisfactory 
with this method. 

Many devices are employed for treating the nasal cavities, 

1 but few are necessary. Some are capable of doing actual harm. 
The Weber nasal douche has thrown watery solutions through 

j the Eustachian tubes into the middle ears, setting up an inflam- 
mation. This is especially liable to happen when any stream 
of fluid is passed into the nostril, for there is a strong inclination 



196 



DISEASES OF THE EAR, NOSE, AND THROAT. 



to swallow provoked by the presence of the liquid. In the ac 
of deglutition the orifices of the tubes open and allow the 



ct 




Fig. 119.— Truax, Greene & Company's Atomizer. 

entrance of the fluid into the tympanic cavity. One of the 
most useful instruments for medicating the respiratory passages, 
after they are properly cleansed, is shown in Fig. 120. It con- 







Fig. 120.— The Universal Vaporizer. 



sists of a nebulizer which projects the most finely diffused spray 
obtainable, and admits of the use of much stronger medicaments 






EXAMINATION AND INSTRUMENTS. . 197 



than are ordinarily used. It is so constructed that the medica- 
ment from one of the nebulizing- globes (E) can be propelled 
into the nose, throat, or middle ear in a steady current, or with 
interrupted currents by tapping on the valve (/). Or the 
inhalents in two or all of the nebulizing globes can be com- 
bined and used at the same instant. 

An important addition to this vaporizer is the air-regulating 
collar below the push-button (/). By this device the amount of 
pressure is easily controlled and shut off altogether, if desired, 
when the interrupted current is employed for inflating the 
middle ears. 

The compressed air is supplied to the circular tube (H) by 




Fig. 121.— The Globe Nebulizer. 



means of attaching the cut-off of the air-reservoir at K. The 
air is admitted to the globes by opening the keys at G. 

For those practitioners who are not supplied with a com- 
pressed-air apparatus the globe nebulizer (Fig. 121) is an ex- 
cellent substitute for the large vaporizer. It is also fitted for 
use with compressed air and is employed in the same manner as 
the vaporizer. Fig. 122 represents an inhalation taken through 
the aseptible face-mask. Fig. 123 shows the inhalation through 
a small vulcanite mouth-tube, and in Fig. 124 the returning 
medicated vapor is seen to issue from both nostrils. Figs. 125 
and 126 illustrate the medication of the nasal passages and vault 
of the pharynx by permitting the vapor to enter one nostril and 
return through the other or through the mouth. In Fig. 127 



198 



DISEASES OF THE EAR, NOSE, AND THROAT. 



the opposite naris is closed while the vapor is made to inflate the 
middle ears as we have already described. 

AVith such perfect instruments as are here shown, and with 
sufficient air-pressure, the most effective treatment is rendered 
possible with accuracy and ease. 

Sprays and Inhalents. 

I have devoted considerable time to the investigation of 

inhalents, and have endeavored to arrive at definite results. 

We know well the action of nitrate of silver or sulphate of 

zinc when applied to mucous membranes, but accurate studies 




Fig. 122. 



Fig. 123. 



Fig. 124. 




Fig. 125. 



Fig. 126. 



Fig. 127 



have not been sufficiently devoted to the physiological actions 
of the large number of inhalents offered for our use. 

These actions should be determined before we apply a local 
remedy to a diseased surface, for the same reasons that no inter- 
nal medicine should be administered without fulfilling a special 
indication for its use. 

In the case of camphor-menthol we have no doubt as to its 
place in therapeutics. We have defined its actions. It con- 
tracts the capillary blood-vessels of the mucous membrane, 
reduces swelling ; relieves pain and fullness of the head, or 
stenosis ; arrests sneezing, checks excessive discharges, and cor- 
rects perverted secretions. We know, also, that it possesses 
antiseptic qualities. 



SPRAYS AND INHALENTS. 199 

Since my introduction of this remedy at the meeting of the 
Mississippi Valley Medical Association, in 1891, it has come 
into quite general use for catarrhal conditions of the upper 
respiratory tract. 

Although I did not recommend it until long after I had dis- 
covered that the union of these two camphors resulted in a fluid 
of the chemical formula C 10 H 18 O, and after becoming satisfied 
that we possessed a valuable remedy in this new drug, I am now 
able to express greater confidence, and to verify former state- 
ments by the experience of others as well as by the daily use 
of it up to the present time. The experimental stage has passed 
and the efficacy of- this remedy is clearly established. Special- 
ists who were at first skeptical as to its virtue have since adopted 
it as a standard remedy in both private and dispensary practice. 
I have taken pains to ascertain the results of their experiences, 
and add them to my own. 

The field of application in which camphor-menthol has 
proved most efficacious is in the following diseases: Coryza, hay 
fever, in tumescent rhinitis (intermittent and alternating nasal 
stenosis), hypertrophic rhinitis, simple sore throat, acute laryn- 
gitis, tracheitis, bronchitis, and after cauterization to prevent 
haemorrhages and inflammation. 

For home use and ordinary office treatment I do not employ 
a stronger solution than the 3 per cent, in lavolin, and for very 
sensitive cases, like hay-fever sufferers, the 1- or 2-per-cent. 
solution at first. The lavolin itself is a bland and soothing pro- 
tective to the membrane, and in the combinations indicated we 
have undoubtedly a most effective and harmless remedy. This 
means a great deal to both patient and physician, for many of 
the sprays in use give indifferent results — or worse. 

Patients should be instructed to treat themselves thor- 
oughly every night at bed-time, by throwing a spray of the 3- 
per-cent. solution from a lavolin atomizer (Fig. 118) into both 
nostrils while slowly inhaling. The rubber bulb should be 
forcibly and rapidly compressed at least eight times for each 
nostril. For the throat, larynx, or bronchial tubes the spray 
should be thrown through the mouth during inhalation. 



200 DISEASES OF THE EAR, NOSE, AND THROAT. 

In diphtheria, croup, etc., in infants, when it is very dif- 
ficult to throw a spray into the throat, the medicine may be 
made to reach the parts by volatilizing it, by placing a few 
drops of the pure, undiluted camphor-menthol in a tea-kettle of 
hot water and causing the patient to breathe the medicated 
steam ; or a few drops can be heated in a spoon over a lamp, 
and its fumes will impregnate all the atmosphere of the room. 
Enough medicine need not be used to cause uncomfortable 
smarting of the eyes. Inflammation of the throat, larynx, 
trachea, and bronchi can be effectually treated by inhaling the 
camphor-menthol steam in this manner. 

I have found that we can prevent haemorrhage and inflam- 
mation, following galvano-cauterization of the turbinated bodies, 
by gently packing a pledget of cotton wet with a 20-per-cent. 
solution of the camphor-menthol between the burned tissue and 
the septum, and leaving it there twenty-four or forty-eight hours. 
It is then replaced by a fresh dressing, and, at the end of four 
or five days, instead of finding sloughs filling the passages, 
swelling, and stenosis, the tissues appear shrunken and mum- 
mified and the strait is clear. Unless the electrode has been 
allowed to cool before removing, no haemorrhage or only slight 
oozing occurs. There is also less discomfort following this 
method than after others. The cotton should not be saturated 
to dripping with the solution, so as to allow it to trickle down 
into the throat, and if too much is used it occasions a copious 
serous secretion. Advantage of this power of the strong solu- 
tion to cause stimulation of the glands and osmosis can be taken 
in treating ozaena and dry catarrh of the nose and throat. The 
weak solutions diminish secretions ; the strong ones increase 
them. 

For self-treatment of the nose and throat patients have 
found much relief by using an inhaler like that shown in 
Fig. 128, which can be carried in the pocket, and contains a 
liquified mixture of equal parts, by weight, of camphor and 
menthol. It has a more soothing and correcting effect on the 
nerves and vessels than menthol alone. It does not become 
irritating, like menthol-crystals, after being used for some time. 



SPRAYS AND INHALENTS. 201 

It can be used unnoticed in public places the instant any irrita- 
tion appears, and thus prevent or cut short attacks. Three or 
four slow, deep inhalations should be taken from it in one nos- 
tril while the other is closed, or until the irritation is relieved. 
The breath should not pass through the inhaler, but out through 
the mouth instead. ' To treat the throat it should be inhaled 
through the mouth. 

If we want a drying, detergent, and protective spray, the 
pine-needle oil in a 2-per-cent. solution will accomplish the pur- 
pose, and it is a most agreeable preparation. In those rare 
cases in which the mucous glands are atrophied and in need of 
a powerful stimulant to excite them to action, the 4- or 10-per- 
cent, cubeb-spray is the most effective, especially when com- 
bined with the 10-per-cent. strength of camphor-menthol and 
lavolin. 

There is a prevalent mistaken opinion that the cubeb-spray 




Fig. 128.— The Author's Camphor-menthol Inhaler. 

is drying to the mucous membrane, while the opposite effect is the 
true one. It is a stimulant and disinfectant. It increases the 
flow of mucus, and if used in too strong a preparation it acts as 
an irritant. Cubeb is useful as a tonic in chronic irritability of 
the pharynx and larynx, especially in the hoarseness of public 
speakers and singers. 

Eucalyptus is antiseptic, and destructive to low forms of 
life. It is a stimulating expectorant, and must not be used in 
very strong solutions, or it becomes an irritant. When com- 
bined with lavolin in the proportion of 20 grains to the ounce 
it is not too strong for the majority of patients, but, as a rule, it 
must be avoided in hay-fever patients. Some of them cannot 
remain in the room where it is being sprayed without suffering 
from paroxysms of sneezing. Carbolic acid combined with 
lavolin, 2 grains to the ounce, is valuable when the antiseptic 



202 DISEASES OF THE EAR, NOSE, AND THROAT. 

and anaesthetic effects are required. It is very useful in ozaena, 
especially when followed with the aristol. 

Alkaline and antiseptic aqueous solutions are necessary for 
properly washing out and cleansing the nasal cavities prepara- 
tory to the application of other medicaments. DobelPs solution 
is the most universally used. It consists of biborate and bicar- 
bonate of sodium, of each 1 drachm ; carbolic-acid crystals, 12 
grains ; glycerin, 2 drachms ; water, enough to make 8 ounces. 
Seller's antiseptic solution is also satisfactory, and is easily and 
quickly made by dissolving one of the tablets in two ounces of 
pure water. These solutions dissolve, loosen, and wash out the 
secretions and crusts, so that the diseased membrane itself can 
be reached. 



CHAPTER XIX. 
DISEASES OF THE NASAL CAVITIES. 

Influenza. 

There are two types of this disease. One is an uncompli- 
cated catarrhal condition of the respiratory tract prevailing 
generally during the changes of the seasons from fall to winter 
and from winter to spring, and may appear at any time during 
the year. The other is of an epidemic nature and is known 
under several names, as follow : The grip ; grippe ; epidemic 
catarrh, or catarrhal fever ; blitz catarrh ; epizootic. Since the 
treatment of the severer variety will include that of the milder, 
we will consider the subject of the epidemic form. 

Epidemics of influenza date back beyond the Christian era. 
and as early as the year 415 B.C. the Athenian army in Sicily 
was afflicted with this trouble. There is a periodical outbreak 
of a similar disease, occurring twice a year, in January and 
August, in the Caroline Islands, from which nearly all the in- 
habitants suffer ; but this is very suggestive of hay fever. In 
the year 1510 the British Islands were visited by a very ex- 
tensive epidemic of influenza, but up to that time no exact 
records of it were written. Since that period there have been 
more than twenty outbreaks of a severe type, besides many 
minor ones. 

The disease usually is first manifested in the far East, gen- 
erally in some part of Russia, and travels rapidly from east to 
west. The greater the facilities for rapid transit, the faster it 
invades the western countries. It has traveled from near St. 
Petersburg to Xew York in six weeks. It prevails in all cli- 
mates and attacks all classes of society, but infants enjoy partial 
immunity. While it has been made the butt of jest by the 
uninformed masses and the subject of ridicule by the unthinking 
trhiers in medicine, it is more to be feared than small-pox or 
cholera. It cannot be quarantined and controlled by protective 

(203) 



204 DISEASES OF THE EAR, NOSE, AND THROAT. 

measures like those diseases, and when it does not kill it blights 
and withers and leaves its deadly sting to blot out one's sight, or 
hearing, or reason, or sows its morbific seeds in other organs to 
insure its victims future maladies. When it first appeared in 
Paris the effects were worse than any of the three epidemics of 
cholera during the thirty years preceding 1884. The influenza 
epidemic of 1891 in Chicago, lasting about six weeks, produced 
the highest mortality the city had ever known. 

Pathology. — The exact nature, cause, and method of origin 
and propagation of this disease are not yet definitely determined. 
It is easier to say what it is not than to say precisely what it is. 
It is not a simple catarrhal affection. It is a specific, infectious, 
and contagious disease. The principal manifestations occur in 
the mucous membrane of the respiratory tract. There are con- 
gestion and swelling of this membrane in the nose, throat, and 
pharynx, and sometimes extending as far as the bronchial tubes. 
In certain cases the inflammation invades the gastro-intestinal 
canal. 

Various bacteria have been found in the sputa of persons 
suffering from this disease. Staphylococci and streptococci were 
especially abundant, but it is still an open question as to what 
actually constitutes the specific infection that gives rise to the 
attack. Some observers believe that the true influenza bacillus 
has been found, while others are of the opposite opinion and 
suggest that the micro-organisms found may be the product 
instead of the cause of the disease. 

It seems reasonable to assume, from the rapidity with which 
the whole organism shows the presence of infection, that it first 
enters the blood. No other theory yet advanced satisfactorily 
accounts for all the phenomena that it presents. 

Etiology. — Epidemic influenza is believed by some to be 
caused by peculiar atmospheric conditions, which would account 
for its rapid extension over a large part of the globe and ap-. 
pearing in widely-separated places at nearly the same time. 
We know that the upper strata of the atmosphere, in which 
volcanic dust is disseminated, will carry these particles to the 
remotest regions of the earth, and that dense poisonous gases 



DISEASES OF THE NASAL CAVITIES. 205 

evolved from subterranean sources may be extruded into the 
great ocean of atmosphere about us and prove detrimental to 
animal life. 

During some invasions meteorological records have shown 
high barometric pressure, drouth, northerly winds, cloudy sky, 
diminution of ozone, and low electrical charge of the air. While 
the prevailing winds have varied greatly in different countries 
during the same epidemic, extremely dry air has been a constant 
factor. This unusual dryness of the air and earth has led some 
to believe that the consequent liberating and floating of the result- 
ing dust in the air and its inhalation and irritating effects upon 
the respiratory passages accounted for attacks. But a severe 
epidemic arose in Russia while the country was covered deeply 
with a carpet of snow, and, moreover, the respiratory system is 
not invariably involved. 

It is claimed by some observers that the epidemic does not 
travel faster than man ; that obstacles to travel, like mountain- 
ranges, obstruct its progress ; that the most popular means of 
communication between people of different countries form the 
routes by which the disease progresses ; and that it first gains 
foothold in large cities, where persons congregate in the greatest 
numbers : post-offices, factories, schools, banks, etc. All these 
facts point to the harboring and conveying of the germs of 
influenza by human beings. 

Symptomatology. — The variations of the disease as it ap- 
pears in different individuals, and even in the same person, are 
susceptible of classification under three natural divisions of the 
subject: as it affects (1) the nervous system, (2) the alimentary 
canal, and (3) the respiratory tract, including the Eustachian 
tube, middle ear, and pneumatic cells of the mastoid process. 
We are especially concerned with the latter form. 

It is not common to see all of these forms affect the same 
patient at the same time, but it is not uncommon to see two of 
them co-exist. For example : The great mental depression with 
extreme prostration of the muscular system that first makes its 
appearance may be quickly followed by the gastric and intes- 
tinal disturbances that add to the exhausted condition already 



206 DISEASES OF THE EAR, NOSE, AND THROAT. 

present. We often see the nervous and respiratory forms com-v 
bined, but not the simultaneous invasion of the air-passages 
and alimentary canal. Two of the three forms are sometimes 
consecutive to each other. To illustrate : One of our younger 
professors in the Post-Graduate School was attacked during the 
epidemic with vomiting and purging and general prostration, 
from which he nearly recovered in five days, when he was seized 
with sneezing, running at the nose, sore throat, hoarseness, and 
mild bronchitis. 

Chilliness and heat may often be marked when the tem- 
perature rises only one or two degrees, but the rise is often to 
103° or 104° F. In addition to a sudden sense of great fatigue 
there often occur shooting pains in the head, pain and muscular 
soreness in the extremities or abdomen, aching of the back and 
loins, and in the respiratory form coryza, pharyngitis, and often 
an invasion of the lower air-tract. 

We have observed that patients with an unusual form of 
middle-ear disease begin to present themselves in both private 
and dispensary practice about one w 7 eek after we become con- 
scious of the presence of an epidemic of influenza. They often 
present this story : " Doctor, I was taken a few days ago with a 
cold in the head, and I had a great pain in my ear last night. 
It broke during the night and ran blood and water." They 
present a picture of acute suffering, anxiety of countenance, 
weakness of the limbs ; coated, indented, and tremulous tongue ; 
and complain of pain radiating over the corresponding side of 
the head. The mastoid is more often involved than in the simple 
middle-ear inflammation complicating influenza between epi- 
demics. The external-ear canal is found to contain bloody 
serum ; the drum-head is red, swollen, and bulging ; and the 
tympanum is filled with discharge. The hearing is usually 
much impaired. 

Diagnosis. — As soon as the catarrhal symptoms of the re- 
spiratory tract make their appearance, the diagnosis is a simple 
matter. The symptoms already enumerated are sufficient to 
decide the question, and the presence of an epidemic will 
suggest the nature of the complaint. 



DISEASES OF THE NASAL CAVITIES. 207 

Prognosis. — Robust individuals are able to resist the attacks 
sufficiently to recover in a few days or weeks, but persons 
already debilitated or suffering from diseases of vital organs are 
prone to succumb either during the attacks or as a sequel to 
them. 

While the general statement may be made that a small 
percentage of cases die during the attacks, this does not convey 
any adequate idea of the actual damage done by an epidemic, 
because, in the first place, such vast numbers of the population 
fall victims to its ravages, and, in the second place, many die or 
are made defective as its sequel. 

Treatment. — The patient is put to bed and the bowels 
relaxed if necessary. When the temperature is high it is re- 
duced with antipyrin or one of its efficient substitutes, and the 
pain and other distressing symptoms are relieved by tablets 
containing a combination of morphia, atropia, and caffeine in 
the proportion of T V grain of morphia with q^-q grain of 
atropia and ^ grain of caffeine (Traux, Greene & Com- 
pany). The morphia relieves the pain and nervous irrita- 
bility, suppresses the excessive secretions, and stimulates the 
circulation ; the atropia elevates the tone of the blood-vessels, 
quickens the pulse, decreases all the secretions except the 
urine, stimulates the respiratory centre, and counteracts the 
constipating effects of the morphia ; and the caffeine stimu- 
lates the nervous centres and the kidneys and diminishes the 
tendency of the morphia to produce nausea. The sneezing 
and nasal discharge cease, the nostrils open up, and the pain 
disappears. 

We treat the nose and throat with a 3-per-cent. solution of 
camphor-menthol in lavolin with the atomizer three or four 
times a day. 

This treatment, with repetition ol the doses as the symp- 
toms demand, minimizes the suffering, diminishes the intensity 
of the disease, and shortens its course. For rheumatic symp- 
toms salicin or salicylate of sodium should be given. Com- 
plicating diseases call for their appropriate treatment on general 
principles. 



208 diseases of the ear, nose, and throat. 

Acute Rhinitis. 

Synonyms. — Cold in the head ; coryza ; acute nasal 
catarrh. 

Pathology. — Simple acute rhinitis is an inflammation of 
the Schneiderian membrane of one or both nostrils. It is more 
common to childhood than adult life, and the aged are rarely 
afflicted with it. Coryza forms one of the symptoms of the 
eruptive fevers, and sometimes occasions more distress than the 
disease it accompanies. 

Etiology. — Taking cold is the commonest cause. The im- 
pression of cold on certain surfaces of the body appears to 
paralyze the inhibitory power of the vasomotor nerves con- 
trolling the capillary circulation of the nasal mucous membrane. 
The most vulnerable surfaces are the back of the neck and head 
and the feet. The climatic and meteorological causes are dis- 
cussed in Chapter I. The nervous temperament predisposes to 
this affection. Wagner {New Yorlc Medical Journal, October 
27, 1894) considers that rhinitic affections are in many cases 
due to the immigration of micro-organisms from the tonsils 
when they are diseased. 

Symptomatology. — The earliest manifestation of cold in the 
head is a sensation of dryness or irritation in the nostril, prompt- 
ing one to snuff the air as if to dislodge some foreign substance. 
This gives place to itching, tickling, or stinging sensations, fol- 
lowed by paroxysms of sneezing, copious flow of serum and 
mucus from the nostrils, suffusion of the eyes, lacrymation, 
flushed countenance, and possibly sensations of constriction and 
pain over the eyes in the frontal sinuses, and headache. 

The discharge becomes acrid and irritating to the nasal 
opening and upper lip, producing redness, excoriations, and 
cracking of the skin over which it spreads. The efforts of the 
patient to keep the nose and lip dry result in the removal of the 
epidermis to such an extent as to leave a raw-appearing surface. 
One of the most distressing symptoms is the nasal stenosis 
produced by the great swelling of the nasal membrane and 
turbinate bodies. This interferes with swallowing as well as 






Plate II 



PLATE II. 



Figure 1. — Posterior view of left nasal cavity in the normal state. 

2.— Lateral " " " " " 

" 3.— Anterior " " " " " 

" 4. — Rhinoscopic " " " " " 

" 5. — Rhinoscopic : ' " " " " mirror slightly turned 

" 6. — Microscopic section of the nasal mucous membrane over the turbinated 
bones. 

a, Superior turbinated bone. i, Vestibule. 

b, Middle " " j, Sphenoid sinus. 

c, Inferior " " k, Frontal " 

d, Eustachian orifice. Z, Epithelium. 

e, Soft palate. m, Submucous layer. 
/, Uvula. n, Corpora cavernosa. 
g, Posterior nasal cavity. o, Fossa of Rosenmuller. 






Figures 7 to 12. — Acute rhinitis, or appearances during an exacerbation of simple 
chronic rhinitis.* 

Figure 11. — Rhinoscopic view of hypertrophied adenoid tissue in the posterior wall 
of the naso-pharynx during an acute exacerbation. 



Figures 13 to 18. — Hypertrophic rhinitis ; anterior, middle, and posterior hypertro- 
phies ; fimbriated adenoid vegetations in the naso-pharynx. 



•^Represented as seen under gaslight. Under natural light the red color is much lighter, 



Plate II 




l J SajQus, Pinxil 



Burk &M C Petri dge, Lith. Phi/a. 






DISEASES OF THE NASAL CAVITIES. 209 



breathing. Respiration takes place entirely through the mouth, 
and the attempt to swallow liquids results in their being forced 
upward into the nasal space or even into the Eustachian tubes. 
The sense of smell is diminished or absent and the voice indi- 
cates the seat of the trouble. It has a characteristic nasal 
quality, and the sounds of m and n cannot be produced. The 
disease may extend to the antrum of Highmore, the frontal 
sinuses, the ethmoid or sphenoid cells, or the Eustachian tubes 
and middle ears. 

Diagnosis. — The group of symptoms described presents so 
characteristic a picture that there is no likelihood of confound- 
ing this disease with any other, but it must not be forgotten 
that it is a symptom of the exanthemata. 

Prognosis. — If the inflammation does not extend to the 
accessory cavities, recovery can be expected in a few days, but 
may be postponed longer in severe attacks. 

Treatment. — The course pursued in the treatment of in- 
fluenza, varying according to the severity of the attack, can be 
relied upon here. Indeed, this disease can be averted by the 
use of the tablets mentioned for influenza, containing caffeine, 
morphia, and atropia. By giving one of these at the onset of 
the attack the symptoms subside with as much certainty as can 
be affirmed of any medicinal specific. The effect of this remedy 
lasts several hours, although the dose is small, and it should be 
repeated in two, four, or six hours if the symptoms begin to 
re-appear. (See page 207.) 

This remedy should never be given through prescriptions 
to patients. I have never allowed them to know the com- 
position of it, and for this reason no patient has ever contracted 
a drug habit through my carelessness. It would be much better 
to give the little tablets gratuitously than to run any risk what- 
ever of becoming responsible for a harmful habit. 

Spraying the nose with a 3-per-cent. solution of camphor- 
menthol in lavolin (Figs. 118 and 119) affords great relief. The 
physiological effects and uses of this remedy are dwelt upon in 
Chapter XVIII. 

The camphor-menthol pocket-inhaler (Fig. 128) affords 



14 



210 DISEASES OF THE EAR, NOSE, AND THROAT. 

much relief in mild attacks. Its uses are given in the pre- 
ceding chapter. It affords not only a very refreshing inhalent, 
but, if employed as soon as the first nasal irritation is felt, the 
symptoms may be checked. 

An important preventive measure is the protection of the 
body from the vicissitudes of the weather. Fabrics of vegetable 
fibre, such as cotton and linen, should not be worn next* the 
skin. Animal fibre, such as woolen or silk, favors absorption 
and evaporation of the perspiration, keeps the temperature of 
the surface of the body equable, and prevents chilling. Woolen 
is preferable to silk, except in the hottest weather, when thick 
silk underwear affords more comfort and sufficient protection. 

Simple Chronic Rhinitis. 

Synonyms. — Chronic coryza ; blennorrhcea ; rhinorrhcea ; 
purulent catarrh. 

Pathology. — This is a chronic inflammation of the nasal 
mucous membrane, generally consequent upon recurring seiz- 
ures of acute coryza. The membrane is swollen and puffy and 
the venous sinuses are dilated and relaxed (vasoparesis). Ex- 
tensive infiltration of the interstitial tissue with serum and leuco- 
cytes occurs, with a consequent hydrorrhcea and degeneration 
into pus-cells. The mucous glands are excited to increased 
activity, necessitating a frequent resort to the handkerchief to 
prevent dripping from the end of the nose. The membrane 
is easily irritated by dust, gases, and sudden changes in the 
weather. 

Etiology. — Exposure to damp and cold and an atmosphere 
loaded with irritating gases or dust act as direct exciting causes. 
A nervous temperament and the strumous diathesis predispose 
to the disease. 

Symptomatology. — The increased nasal discharge is the 
most prominent feature, and the end of the nose may become 
so irritated as to give it a red and swollen appearance. The 
secretions consist of mucus and serum, or pus formation takes 
place to such an extent as to fill the nares with a yellow dis- 
charge. Its presence provokes frequent hawking and expecto- 



to- 



DISEASES OF THE NASAL CAVITIES. 211 

ration. Sneezing is not a constant or frequent symptom as 
compared with acute coryza or hay fever. An annoying sensa- 
tion of fullness in the head — especially if the infundibulum, or 
passage-way from the frontal sinus to the nose, is obstructed — 
may lead one to suspect involvement of the sinus. 

There is a tendency for this disease to extend to the Eusta- 
chian tubes, the middle ears, or the nasal ducts, causing impair- 
ment of hearing and obstruction of the natural tear-passages. 
The thickening of the membrane and the turgescence of the 
turbinate bodies so constrict the meatuses as to impart a nasal 
intonation to the speech. The walls of the passages are 
frequently seen to be agglutinated together by a viscid, tena- 
cious secretion, or bathed in pus. The membrane is generally 
redder than the normal, but in the variety in which the 
hydrorrhcea is abundant it may appear of a pale-pink tint or 
even livid. 

The secretions may become dry and inspissated to the 
degree of crust formation. These adhering crusts excite a 
desire to pick at the nose until they are removed. This con- 
stant source of irritation and depriving the septum of its 
natural protection in the process of repair result in perforation 
in that part of the cartilaginous septum near the border of the 
nares. 

Diagnosis. — To distinguish between this and hypertrophic 
nasal catarrh it is essential to use the probe and cocaine. When 
the probe is pressed upon the turbinals in the simple form it 
sinks into a body comparable to a wet sponge, for the tissues 
are distended with the infiltrated fluids. The depression caused 
by pressure fills slowly like that of a dropsical body. In the 
hypertrophic variety the probe meets with a firm, resisting, 
fibrous tissue, which possesses greater resilience. Cocaine 
contracts the tissues, in the simple form, until they hug the 
bone, leaving a wide air-space ; but not so in the hypertrophic 
variety. In the latter the surface is uneven, in the former 
smooth. 

Prognosis. — Patients are skeptical as to the curability of 
nasal catarrh. It is so common an affection, especially in the 



212 DISEASES OF THE EAR, NOSE, AND THROAT. 

region of the Great Lakes, that the inhabitants think that, as a 
matter of course, they must expect to suffer from it. However, 
with an advantageous combination of treatment and hygienic 
measures, a cure can confidently be predicted. But one is not 
warranted in promising no return of the trouble under provoca- 
tive conditions. 

Treatment. — The first requisite to success is cleanliness of 
the nasal cavities. This is best obtained by the use of sprays 
such as Dobell's and Seller's solutions, mentioned in Chapter 
XVIII. These can be injected successfully with the hand- 
atomizer (Figs. 118 and 119) if one lack a large air-compressor. 
Eight pounds' pressure is sufficient to thoroughly wash the 
cavities without any likelihood of invading the Eustachian tubes. 

After the membrane is thoroughly cleansed oleaginous 
sprays are indicated to protect the surface, stimulate the absorb- 
ents, contract the blood-vessels, disinfect, and render the mucosa 
less sensitive. These remedies are treated of in Chapter XVIII. 
An effective treatment consists in throwing a fine nebula of a 
10-per-cent. solution of camphor-menthol in lavolin, by means 
of the hand-dilator (Fig. 18), followed by a spray consisting of 
calendula, 4 parts; hamamelis, 8; pinus strobus, 8; lavolin, 
80. Or the following: Eucalyptol, 30 parts; carbolic acid, 10; 
menthol, 4 ; oleate of aconitine (2 per cent.), 2 ; oil of sassa- 
fras, 10; lavolin, 944. Camphor-menthol in the nebula does 
not bathe the membrane with the liquid, but relieves the irrita- 
bility and stenosis and prepares the parts for the coarser spray 
which will remain in contact with the diseased surface for many 
hours. 

This treatment is best given two or three times a week by 
the surgeon, while the patient pursues a home treatment with a 
suitable atomizer and medicament in order to prolong the effect 
of each office treatment and render it continuous. Cocaine is 
not mentioned by the author as a therapeutic agent, because it 
is not of such a nature as to effect permanent results, and 
because of the imminent danger of converting one's patron into 
a pemicious-drug slave. Cocaine has no place in my practice 
except as an anaesthetic in surgical procedures. 






DISEASES OF THE NASAL CAVITIES. 213 

Dilators of medicated gelatin, gum elastic (Fig. 129), hard 
rubber, and metal are useful in reducing the engorgement of 
the turbinate bodies and overcoming contact and pressure of 
these bodies upon the septum. The bougies adapted in contour 
and size to each individual case are introduced between the 
turbinals and septum for a few minutes at first, beginning with 
the smaller, and used on the same principle as sounds and 
dilators in other departments of surgery. 




Fig. 129.— Goodwillie's Nasal Dilator, or Tube. 

When the engorgement of the vessels of the turbinate 
bodies produces great intumescence of those structures and con- 
sequent constriction of the nasal passages that proves unyield- 
ing to the methods already mentioned, the cautery is indicated. 
The galvano-cautery is the most effective, but in its absence 
chemical cauteries can be substituted. A detailed description 
of the apparatus and methods will be found in the treatment of 
hypertrophic rhinitis. The question of proper clothing is con- 
sidered in the treatment of acute rhinitis. 



CHAPTER XX. 

DISEASES OF THE NASAL CAVITIES, CONTINUED. 

Hay Fever. 

Synonyms. — Nervous catarrh; nervous coryza; hay asthma; 
rose cold ; June cold ; July cold ; peach cold ; summer catarrh ; 
autumnal catarrh; pollen poisoning. The Latin equivalents are 
catarrh us sestivus; coryza vasomotoria periodica. French equiv- 
alents: ca tan-he d'ete ; catarrhe de foin. German equivalents: 
Friihsommer-catarrh ; Heu-asthma. Italian equivalent: asma 
dei mietitori. 

Pathology. — In a paper read before the Section on Psycho- 
logical Medicine and Nervous Diseases of the Ninth Inter- 
national Medical Congress in Washington in 1887, the author 
argued the neurotic character of this disease. The assembly, 
which was very large and representative, agreed almost unani- 
mously to the theory that hay fever is a neurosis. Only three 
members who participated in the discussion dissented fiom 
this view. 

The name "hay fever" is a misnomer. It is employed to 
designate a condition to which numerous other terms have been 
applied with equal fitness. To the array of names already in 
use, ill-chosen because they are misleading, I have had the 
temerity to add another. In a published lecture, delivered in 
the Chicago Medical College in 1885, I proposed the term 
"nervous catarrh." Since then several authors have adopted 
this expression. One writer, however, calls it nervous coryza ; 
but coryza is from the Greek xopv^a, signifying only a running 
at the nose, while the word catarrh, from xarappeo, admits of a 
much broader application and, with properly modifying adjec- 
tives, may be used to designate affections of various mucous 
membranes. Coryza is a specific term ; catarrh is generic, and 
obviously is the more correct one to characterize a disease which 
is not necessarily confined to the nasal cavities. Nervous catarrh 
(214) 



DISEASES OF THE NASAL CAVITIES. 215 

is so comprehensive a term, and is so tersely suggestive of the 
pathology and symptomatology of certain neurotic derange- 
ments, as to be susceptible of a much larger usefulness than 
has been accorded it. To illustrate : There is a truly nervous 
intestinal catarrh which attacks and leaves a certain class of 
individuals of the nervous temperament as suddenly as an 
attack of hay fever does. I have, known a musician to suffer 
from severe attacks of diarrhoea just previously to his appear- 
ance before an audience which he was announced to entertain. 
Immediately after his performance all symptoms of intestinal 
disturbance would vanish, only to return again at his next ap- 
pearance in public. I might cite a case of an orator of the 
evening who was similarly afflicted. The nervousness induced 
by the contemplation of addressing his audience would so react 
on the nervous supply of the intestinal tract as to cause sudden 
and copious diarrhoea. No sooner would his oration be finished 
than all unpleasant symptoms ceased. I have known surgeons 
to be similarly affected. We have nervous dyspepsia occasioned 
by mental emotions. A certain combination of objective and 
subjective causes operating on one individual produces morbid 
phenomena referable to the mucous membrane of the turbinated 
bodies, resulting in an attack of hay fever, — nasal nervous ca- 
tarrh. In another, the seat of the resulting manifestations will 
be in the bronchial mucous membrane, eventuating in an attack 
of asthma, — bronchial nervous catarrh. In yet another the in- 
testinal mucous coats are the scene of this breaking of a nerve- 
storm, resulting in copious watery discharges, — intestinal nervous 
catarrh. All these are undoubtedly co-ordinate morbid con- 
ditions of the nervous system, finding expression in exaggerated 
and perverted functional activity. 

The pathology of this disease has been evolved from a 
chaotic state, in which it remained from the time of its first 
description by Dr. Bostock, of London, in 1819, until the last 
decade. Instead of looking upon hay fever as a simple con- 
gestion or inflammation of the Schneiderian membrane, as emi- 
nent English authorities have in the past, prominent American 
authors favor the neurotic theory. In this connection it is inter- 



216 DISEASES OF THE EAR, NOSE, AND THROAT. 

esting to note that a writer for the Lancet treats of common nasal 
catarrh as a reflex neurosis, and, in support of his position, 
adduces numerous instances in which purely nerve-remedies 
succeeded in arresting attacks of acute coryza. 

Although this malady is essentially due to an abnormal 
susceptibility of nervous tissue, there exists no organic lesion of 
the nervous centres to which the disease is attributable. Being 
a functional disturbance, it never destroys life, and no oppor- 
tunity is afforded the neuropathologist to make post-mortem ob- 
servations. But, if the affection be a reflex neurosis, can we 
hope for microscopy to determine with precision the condition 
of nervous structure which primarily constitutes the disease \ 

The arrangement of the nervous supply of the respiratory 
passages is favorable to the existence of reflex nervous phenom- 
ena. One sympathetic nervous centre, the sphenopalatine 
ganglion, supplies branches to the lining membrane of the nose, 
pharynx, and Eustachian tubes. It has a motor, a sensory, and 
a sympathetic root. It communicates with the facial and pneu- 
mogastric nerves, thus uniting in the closest connection the 
nose, pharynx, middle ear, larynx, and bronchi. Furthermore, 
the Schneiderian membrane is continuous with the lining mem- 
brane of the nasal duct and eyelids, the pharynx, Eustachian 
tubes and tympana, the larynx, trachea, and bronchial tubes. 
Ablation of the sphenopalatine ganglion sets up a severe catar- 
rhal state of the Schneiderian membrane. A congestion once 
started in this structure may extend with unobstructed facility 
to the contiguous membranes, very like the spreading of an ery- 
sipelatous inflammation from one area of the skin to another. 
But the continuousness of the membranes throughout these 
various organs does not satisfactorily account for all the symp- 
toms produced in one part by impressions upon another. Cer- 
tainly an inflammation in the throat may extend along the 
Eustachian tube to the tympanum, but there is no such reason 
to account for the sudden transitory tinnitus aurium which 
occurs in some persons immediately upon the ingestion of a 
draught of cold water or the inhalation of tobacco-smoke, or for 
the cough which is occasioned by the contact of instruments 



DISEASES OF THE NASAL CAVITIES. 217 

with the external auditory meatus or with the inferior turbinated 
body or the septum nasi, or for the paroxysm of sneezing pro- 
duced by irritating the scalp. All these symptoms are exam- 
ples of reflex nervous impulses, and these intimate sympathetic 
relations between various portions of the animal economy ex- 
hibit themselves with exceptional force in patients of a nervous 
temperament. 

The theory that lesions situated in the nasal cavities may 
be responsible for the existence of common asthma is generally 
accepted, and this is directly in the line of our reasoning, for it 
argues the reflex neurotic character of a disease which possesses 
close kinship to hay fever not only in its etiology, symptoma- 
tology, and therapeutics, but in the morphology of its secretions. 
The manner in which exciting causes bring about attacks in 
hay fever is much the same as in the case of asthma. In a hay- 
fever subject, let brilliant rays of light fall upon the retina, or 
dust impinge upon a sensitive area of mucous membrane, and 
what occurs] The end-organs of the sensory nerves supplying 
the part affected, being oversensitive to the presence of that 
particular kind of stimulus, are instantly thrown into a state of 
intense excitation or irritation. Immediately the impression is 
flashed along the sensory nerves to a nervous centre, — brain or 
ganglion ; thence, changed to motor impulse, it is switched back, 
on the one hand, along the vasomotor nerves to the blood-vessels 
of the seat of irritation, causing dilatation, engorgement, swell- 
ing, and flux ; and, on the other hand, along the pneumogastric 
and sympathetic nerves to the muscles concerned in the act of 
sneezing, and, through extensive sympathetic nervous relations, 
all the respiratory tract and its connections may participate in 
the disturbance and become involved in a fully-developed attack 
of hay asthma, — sneezing, coughing, wheezing, nasal flux, 
expectoration, and lacrymation. 

Thus it appears, from the manner in which paroxysms of 
hay fever are started and developed, that there are three con- 
ditions upon which the existence of the disease depends: (1) 
abnormally susceptible nerve-centres, (2) hyperesthesia of the 
peripheral termini of the sensory nerves, and (3) the presence 



218 DISEASES OF THE EAR, NOSE, AND THROAT. 

of one of a large variety of irritating agents. Exclude one of 
these conditions and the paroxysms are prevented. Allay the 
susceptibility of the nervous centres by certain cerebral sedatives, 
and an attack is averted or arrested. Anaesthetize the nervous 
supply of the oversensitive areas and the result is the same. 
Remove the patient beyond the reach of exciting causes and he 
is as comfortable as anv mortal. 

Another fact in support of the theory that this is a func- 
tional disease of the nervous system is its hereditary character. 
I might quote many illustrative cases, but three representative 
ones will suffice: In Dr. Morrill Wyman's family there were six 
sufferers from hay fever besides himself. In the family of the 
Hev. Henry Ward Beecher there were two besides himself, and 
in the family of Chief- Justice Shaw there were six members who 
had different forms of this distressing malady. To be sure, 
heredity alone does not establish a neurotic character ; but, 
taken in connection with all the other facts in the case, it is a 
weighty argument in support of the assertion that this is a con- 
stitutional disorder of a neurotic type. 

Again, the nervous temperament is the predominating one 
in this class of patients, — an argument which needs no eluci- 
dation, — and the same may be remarked concerning asthmatic 
sufferers. The periodicity of the disease points to nothing if 
not to its nervous nature, for one cannot conceive how the 
pollen theorists from their point of view can reconcile this 
feature of the complaint with their own doctrine. Is it reason- 
able to assume that the pollen of various plants that give rise 
to attacks in different individuals will be set free to float away 
on their fructifying pilgrimages on exactly the same day, and at 
nearly the same hour, each recurring year, and that they will 
reach the nostrils of sufferers in their varying localities and 
situations and vocations simultaneously year after year'? The 
variations that occur in the yearly advance of the seasons pre- 
clude this hypothesis. And, again, the identity of the different 
forms of the malady strengthens the nerve theory, while it 
weakens the pollen argument, for it shows that the disease exists 
under conditions that are the least favorable to the operation of 



DISEASES OF THE NASAL CAVITIES. 219 

pollen ; in fact, where the pollen theory is inadmissible, — in the 
winter and spring. I do not undervalue the importance of 
pollen as an exciting cause, but I wish to be understood as 
maintaining that it constitutes only one of three factors which 
render the existence of the disease possible. 

Other arguments that may be briefly mentioned are the 
suddenness of the onset and disappearance of attacks, the fact 
that the most potent palliatives are nerve-sedatives, tonics, and 
stimulants, and that mental emotion and physical exertion may 
prevent or arrest paroxysms. 

The chief argument urged against the nerve theory is that 
many hay-fever patients have diseased nasal cavities. But we 
may say the same of that much larger proportion of our popu- 
lation who have no experience with hay fever. That we should 
find nasal hypertrophies, etc., concurrent with hay fever is not 
surprising in this catarrh-producing climate. Indeed, the dis- 
eased turbinated tissue may be a coincidence or sequence rather 
than the cause, for it is natural to suppose that years of con- 
stantly recurring attacks of even a functional disturbance of the 
vasomotor supply of these parts would result in a passive hyper- 
emia which would eventuate in proliferation of cells in the 
mucous and submucous tissues, and the growth of hypertrophies 
which might serve as a nidus for the reception and retention of 
irritating agents. But the argument that this condition is 
responsible for hay fever in infants, youths, and even in adults 
in whom there is no evidence of inflammatory changes before 
or between attacks, is not tenable. The paroxysms do not so 
much resemble symptoms of an inflammation as they do an 
irregular and explosive discharge of a superfluity of nervous 
force, — a nerve-storm, if the expression may be permitted. It 
has been claimed that destructive treatment of the sensitive 
areas in the nasal cavities would permanently cure hay fever, 
and many cases have been so treated by American physicians 
during the last twelve years. However, the most sanguine 
practitioners of this method have confessed disappointment at 
the results. Cases that were supposed to have been cured still 
suffer, while others are benefited. So far as I have been able 



220 DISEASES OF THE EAR, NOSE, AND THROAT. 

to obtain definite data, they demonstrate that not more than 
one-half the number cauterized are claimed to be cured. This 
points to the fact that it is not a simple local inflammatory dis- 
ease. If it were, -the treatment should be attended with greater 
success. For the reasons set forth one cannot expect this 
method to cure all ; but, granting that it may cure many, the 
nerve theory would not suffer in the least by the admission, for 
it assumes a pathological condition of the receptive end-organs 
of the nerves as well as of the perceptive nerve-centres. Elimi- 
nate the susceptibility. of either the central or peripheral nervous 
system, and you remove an essential element in the disease, — 
destroy its entity. But what shall we say of that other large 
proportion of patients in whom paroxysms are produced by irri- 
tation of the retina, the scalp, etc., or by chilling of the skin? 
Are we to be logical and, reasoning from analogy, must we 
destroy the sensitive areas, enucleate our patients' eyes, or scalp 
or skin them 1 Yet, if you follow the reasoning of this school 
of theorists to its logical conclusion, it will lead to this reductio 
ad absiirdum. 

The neurotic theory is supported by the nature of the fol- 
lowing causes : Electric light and gaslight ; overexertion ; 
anxiety ; indigestion ; dampness ; chills ; gases ; feathers ; per- 
fumes ; odors from animals ; dry, hot, and impure air ; various 
kinds of fruit, etc. It will be observed that pollen and dust 
do not necessarily enter into the causative nature of these 
excitants. 

This theory receives support also from the fact of the 
excessive irritability and nervousness which patients experience 
just preceding and during attacks. The co-ordinate action of 
muscles is affected, and they complain of feeling jerky and ill- 
tempered for the time. 

In studying this disease it should not be forgotten that the 
statements of sufferers relative to the history and phenomena of 
their maladies should be given greater credence than is usually 
accorded the assertions of other classes of patients, inasmuch as 
they enjoy the distinction of being superior to the average in 
intelligence and culture. This is far from being an idle asser- 



DISEASES OF THE NASAL CAVITIES. 221 

tion, for it voices the experience of the best authorities and is 
borne out by a reference to the list of membership of the United 
States Hay Fever Association. 

I cannot consider the treatment of this subject as approach- 
ing completeness without referring briefly to two other important 
points. Microscopists have examined the nasal and bronchial 
secretions from hay-fever and asthmatic sufferers, with the 
result, it is claimed, of establishing the kinship of the two dis- 
eases by demonstrating the presence in both of products called 
" gravel." It is believed that this so-called gravel accumulates 
in the secretions of the respiratory passages, and acts as a local 
irritant in the same manner that any foreign body would. 

The force and analogy apparent in the following facts 
relating to neuroses of the skin serve to emphasize the truth 
in the nerve theory : Intense itching over the surface of the 
whole body may be produced by morbid alterations in the 
ovaries or uterus, anomalies of menstruation, diseases of the 
kidneys, liver, etc. Neumann says : " There is no doubt that a 
large proportion of cutaneous diseases depend upon disorders of 
the vasomotor nerves which cause certain derangements of circu- 
lation in the arteries, veins, and cutaneous glands. Anaemia and 
hyperemia of the skin happen from vasomotor irregularities, — 
some from the brain, some from the spinal cord, — or from the 
action of cold, or the electric current, etc." Now, since it is 
admitted that there are both immediate and reflex functional 
nervous disorders of the skin, with what show of reason can it 
be denied that there are similar neurotic disturbances of that 
other skin which covers the interior surfaces of the body 1 The 
latter membrane is more vascular, more delicate, more sensitive, 
and more highly organized than the skin. It possesses sus- 
ceptibility to all agents which affect the skin, and to many 
others besides. For example, noxious gases, to which the skin 
is insensible, will irritate the mucous lining of the respiratory 
organs. The same laws that govern the action of the vaso- 
motor nerves of the skin also regulate the vasomotor supply of 
the mucous membranes. If itching and burning of the skin 
are produced by morbid alterations in the ovaries, so is pruritus 



222 DISEASES OF THE EAR, NOSE, AND THROAT. 

ure throe produced by disease of the bladder; pruritus nasi is 
generally accepted as a sign of worms in children ; urticaria 
results from irritation of the gastric or intestinal mucous mem- 
brane ; so may asthma arise in the same manner or from an 
irritant applied to the post-nasal mucous surface ; ear-cough is 
occasioned by contact of instruments with the skin ol the ex- 
ternal auditory canal ; and hay-fever paroxysms result from 
irritation of the retina, the upper lip, or the scalp, or from 
chilling the skin. 

All the facts in our possession force us to the conclusion 
that the weight of testimony is in favor of the doctrine that hay 
fever is a reflex functional nervous disease. 

URIC ACID AS A CAUSE OF HAY FEVER. 

Uric acid exists in the blood in the proportion of about one 
to thirty-three of urea in health. When this proportion is dis- 
turbed by a relative increase of the uric acid, certain disturb- 
ances of a vascular and neurotic character arise. The effects of 
uric acid in producing these disturbances have been the subject 
of an extensive and interesting series of experiments by Alex- 
ander Ilaig. For years he was a sufferer from migraine, and 
studied in his own person the relation of uric acid to the pro- 
duction of attacks of this disease, and the effects of anti-uric- 
acid treatment in subduing attacks, and of diet in preventing 
them. I desire at the outset to acknowledge my great indebt- 
edness to this paintaking observer for many of the facts adduced 
here. (See " Uric Acid in the Causation of Disease," Haig, 
1896.) 

First, let us consider what the effects of an excess of uric 
acid in the blood are. The disorders of the nervous system that 
Murchison associated with lithoemia are : aching pains in the 
limbs and lassitude, pain in the shoulder, hepatic neuralgia, 
severe cramps in the legs, headache, vertigo and temporary dim- 
ness of vision, convulsions, paralysis, noises in the ears, sleep- 
lessness, depression of spirits, irritability of temper, cerebral 
symptoms, and typhoid state. 

Ilaig maintains that the presence of uric acid in excess 



DISEASES OF THE NASAL CAVITIES. 223 

accounts for the exacerbation of pains in rheumatism and gout, 
and Lever contends that these diseases are primarily due to the 
action of this acid on the brain, the spinal cord, or the solar 
plexus of nerves. In persons suffering from intense pruritus, 
uric acid and the urates have been found in excess. 

Ebstein believes that uric-acid deposition acts as an exciter 
of inflammation in the tissues in which it is deposited. 

Quinquaud studied the effects of uric acid on the skin. He 
administered 3 to 6 grains a day to the human subject. The 
most common results were boils and patches resembling eczema, 
— the dermal analogue of coryza. 

Thomas J. Mays attributes attacks of angina pectoris to 
" the increased formation of uric acid, which is incidental to the 
gouty and rheumatic diathesis." lie agrees with Ilaig in 
attributing migraine to the irritating effects of uric acid. 

Conklin details a number of well- marked cases of nervous, 
mental, nephritic, and other diseases that support the proposi- 
tion that they are the result of the action of uric acid. 

N. S. Davis and others add the following to the list of 
manifestations of uricacidsemia : Loss of appetite, nausea and 
vomiting, flatulent indigestion, diarrhoea, intense itching, 
asthma, blindness, deafness, numbness of the skin and creep- 
ing sensations, hyperesthesia and pain in the skin, impaired 
memory, melancholia, delirium, epilepsy, and coma. 

Observe the symptoms of uric-acid irritation that are closely 
allied to paroxysms of nervous catarrh : asthma, intense itching, 
oversensitiveness and other nervous disturbances of the skin, 
neuralgia, sick headache, irritability of temper, etc. The first 
three symptoms often characterize attacks of nervous catarrh, 
and highly moral persons, like the late Henry Ward Beech er, 
are seized with an almost irresistible impulse to accompany their 
storms of sneezing with a shower of profanity. Sick headache 
sometimes alternates with these attacks, and at other times takes 
the place of them. 

While suffering from migraine Ilaig found the uric acid 
increased to the proportion of one in twenty or twenty-five of 
urea, whereas before and after attacks he found it as one to 



224 DISEASES OF THE EAR, NOSE, AND THROAT. 

forty, and the headache was proportioned to the excess of uric 
acid over the urea, and not to the amount of alkali used to 
bring the uric acid out. The mental condition varied directly 
with the relative amount of uric acid in the urine. The excre- 
tion of the acid was greatly diminished before the attacks, — i.e., 
during mental exaltation. 

I have learned, while writing upon this subject, that 
Leflaive analyzed the urine before and during attacks of hay 
fever, and found uric acid in great quantity just before the 
attack and half that quantity during the attack. Some of this 
may have been washed out of the system through the profuse 
perspiration that occurs during the violent sneezing. 

In 1893 I proposed the uric-acid theory of hay fever in the 
first prize-essay of the United States Hay Fever Association, and 
at the meeting of the American Medical Association the same 
year I advocated the same theory. So far as I knew, I was the 
first to propose this doctrine. In 1894 I learned that Shawe 
Tyrrel, of Toronto, had published a paper in 1892, entitled "A 
Predisposing Cause of Hay Fever," advocating the same theory. 
Independently of each other, our studies of the subject forced 
us to arrive at the same conclusions, and I wish to accord Dr. 
Tyrrel full credit for his work. Had I known of it before 
publishing my two essays on the subject, I should have taken 
pleasure in referring to his paper. 

Haig says: "Uric acid in the blood contracts the arterioles 
and capillaries all over the body, producing the cold surface and 
extremities, raising tension of pulse, and, according to Marcy's 
law, that pulse-rate varies inversely as the arterial tension, slow- 
ing the heart. Headache is a local vascular effect of the uric 
acid. Excretion of this acid may even explain the mental 
depression and irritability and their results in the excess of 
suicides and murders in July. There is an excessive secretion 
of this acid in the warm months, and a minus excretion in cold 
weather. During plus excretion there will be high arterial 
tension, with anaemia of the brain, bad temper, etc. At this 
time a dose of acid would free the brain circulation from the 
power of the uric acid, and produce, as Roy and Sherrington 



DISEASES OF THE NASAL CAVITIES. 225 

have shown, an increase in its size and a free flow of blood in its 
vessels." 

Peiper says that alkalescence of the blood is diminished in 
all fevers. Corroborative of this, Haig found, during an attack 
of influenza in 1890, that there was a rise in the acidity of his 
blood, urine, and tissue-fluids, thus driving the uric acid out of 
these fluids, diminishing its excretion, and causing its retention 
in the body. 

Bertillon says that suicides increased 40 per cent, in France 
after the influenza epidemic. This may be accounted for by the 
accumulation of uric acid in the body during the diminished 
alkalinity of the blood, and when the blood regained its normal 
alkalinity the stored acid was taken into the circulation and 
produced its characteristic irritability and depressing effects. 

In health about 5 to 8 grains of uric acid are secreted every 
twenty-four hours, and it is readily soluble in the blood, which 
is slightly alkaline. If there is increased formation of this acid, 
no harm results so long as it is properly eliminated and the 
ratio between it and the urea is not disturbed. 

Haig found that by diminishing the alkalinity of the blood 
he freed it from uric acid, relaxed the arterioles, and relieved 
headache and mental depression. Increasing the alkalinity 
augmented the acid excretion, contracted the arterioles, slowed 
the circulation of the blood, and caused languor, depression, 
headache, and, in epileptics, a fit. Epilepsy, migraine, spas- 
modic asthma, etc., are, like neurotic catarrh, functional nervous 
diseases. What Haig says concerning epilepsy and migraine 
may be affirmed of asthma and nervous catarrh : " They may 
come on early in life, last for years or the whole of life, tend to 
recur at more or less regular intervals, are met with in members 
of the same family, and may afflict one and the same patient, — 
now a fit, now a headache, — alternating or together. Epilepsy 
and headache, gout and rheumatism are very commonly met 
with in the same family." 

Broadbent thinks that the convulsions of epilepsy are brought 
on by the slowing of the circulation and consequent cerebral 
anaemia, in the same way as convulsions after great haemorrhage. 

15 



226 DISEASES OF THE EAR, NOSE, AND THROAT. 

As we have seen, the effect of an excess of uric acid in the 
blood-vessels is to contract them, which, in the vessels of the 
brain, produces cerebral anaemia. This condition appears to 
obtain in nervous catarrh, and the attacks are relieved by such 
remedies as nitrite of amyl, etc., which relieve anaemia of the 
brain. 

This uric-acid theory of nervous catarrh is not antagonistic 
to the present status of medical opinion or surgical treatment, 
but, on the contrary, explains questions that were inexplicable 
before. As a tumor or hypertrophied bone may give rise to 
convulsive seizures in epilepsy, and as its removal may be fol- 
lowed by relief when no other structural cause exists, so in 
nervous catarrh, where new growths and other lesions of the 
nasal mucous membrane are present, the attack may be started 
by the accumulation and the suddenly setting free of uric acid. 
This precipitates the paroxysm by its irritant action, which finds 
expression in the group of symptoms characteristic of nervous 
catarrh or asthma, instead of some one of the other allied dis- 
eases. The particular form of manifestation may be determined 
by the growth, or seat of irritation, located in the nasal cavities. 
Where this is the onlv determining: factor of the nature of the 
morbid symptoms, no other organic disease having resulted 
from the long-standing trouble, the removal of such a peripheral 
source of irritation may give relief from these symptoms, but it 
may not prevent the uricacidaemia from switching off into other 
kindred lines of disturbances if it be not corrected. 

The uric-acid theory makes clear the reasons why some 
persons suffer from attacks of nervous coryza under certain 
favorable conditions in winter, as well as during the warm 
months. It also unifies all the various forms of hay fever. 
They are all variations of nervous catarrh. 

Patients of this class are sometimes affected more or less by 
functional aphasia. Haig's father suffered, from time to time 
for a large part of his life, from this trouble, and in old age had 
organic aphasia with right hemiplegia. The same functional 
disturbance afflicted ITaig very markedly, at times of excess of 
uric acid in the blood, with mental depression, lethargy, and 



DISEASES OF THE NASAL CAVITIES. 227 

headache. The histories of such cases are paralleled by the 
histories of nervous catarrh in many families. 

The periodicity of nervous catarrh has a counterpart in 
migraine that comes once in every seven, ten, fourteen, or thirty 
days, for years or for life. It may last one day or less, rarely 
two, and is worse in the morning. 

In the last published paper of the late A. Reeves Jackson 
he expressed his conviction that various neurasthenic symptoms 
— sleeplessness, headache, vertigo, neuralgia, vague pelvic symp- 
toms, muscular twitchings, vasomotor disturbances, etc. — are 
dependent really upon the lithic-acid diathesis. He wrote : " If 
this fact were duly recognized it would remove some of the 
cases from the list of those which are an opprobrium." 

L. C. Gray says : " Influenza, ague, and other fevers store up 
uric acid in the body." There are several causes that determine 
the manner in which the irritation produced by an excess of 
uric acid may express itself. These are central, peripheral, and 
hereditary causes. " The structure of the nerve-centres and 
the distribution of its vessels not only determine the kind of 
disturbances which uricacidasmia will produce in any given case, 
but also explains why one individual suffers in this way from 
functional nervous disorders, while another, with about as much 
uric acid in his blood and body, escapes. When the nervous 
system is depressed by fatigue, deficient food, etc., a smaller 
amount of uric acid in the blood will suffice to produce dis- 
turbance of function than at other times. If uricacidaemia is 
prevented, the nervous system will not itself originate disturb- 
ances. This knowledge of the effects of lithaemia gives complete 
power to produce or remove the vascular conditions, and the 
nervous disorders which are secondary to (consequent upon) 
these conditions, by proper diet and treatment " (Haig). The 
arguments that apply to migraine are just as forceful in the case 
of nervous catarrh. The peripheral causes — neoplasms, hyper- 
trophies, etc. — have already been considered. 

Heredity is probably the chief factor in determining the 
direction in which the uric-acid diathesis will afflict an indi- 
vidual, whether it results in migraine, angina pectoris, asthma, 



228 DISEASES OF THE EAR, NOSE, AND THROAT. 

nervous catarrh, or some other neurosis ; but undoubtedly acci- 
dental or acquired conditions may act as directing or localizing 
agents. For example of the latter class : a student who is pre- 
disposed to such a neurosis accidentally inhales the fumes of 
burning phosphorus in the laboratory, and this excites the first 
attack of his nervous disorder, which naturally, under these 
conditions, takes the form of asthma. On the other hand, many 
attacks of severe cold, some injury to the nose, or the devel- 
opment of a polypus may determine the nasal form of neurosis, 
or nervous catarrh. I have such cases in mind. 

We can produce and control attacks of nervous catarrh at 
will by treatment and diet the same as we can migraine. I was 
first led to experiment with an anti-uric-acid treatment of nerv- 
ous catarrh by my endeavors to find a solution to the problem 
why paroxysms of this disease attack sufferers regularly in the 
morning. These attacks come on about the same time, morning- 
after morning, although the previous afternoon and evening- 
may have been free from suffering, and the night one of restful 
repose, with no direct access to dust-laden atmosphere from 
without and no change in the contents of the sleeping apart- 
ments. The following facts appear to answer this question : 
The blood is the most strongly alkaline between the small hours 
of the morning and 9 a.m., when it reaches its greatest alka- 
linity. The more alkaline the blood, the more freely soluble is 
the uric acid. Therefore, in the morning hours the blood is the 
most heavily charged with this irritant, and during these hours 
patients suffer the most from angina pectoris, migraine, nervous 
catarrh, and other functional nervous disorders. 

The blood is the most acid during the hours of bodily 
activity, and it reaches its maximum of acidity about midnight. 
During this time there is only a small secretion of uric acid, 
and the amount circulating in the blood is minute. As the 
blood begins to increase in alkalinity in the morning it dissolves 
the uric acid out of the more alkaline tissues in which it has 
been stored, — the liver, spleen, cartilages, joints, and fibrous 
tissues, — and with the increasing alkalinity and solvent proper- 
ties of the blood it becomes rich in uric acid until it produces 



DISEASES OF THE NASAL CAVITIES. 229 

the drowsiness, heaviness, or other nervous phenomena peculiar 
to any given case. 

Joal found, among 127 cases of hay-fever patients, a family 
history pointing to the uric-acid diathesis in 107 cases, and in 
67 cases among his 71 adult patients the diathesis was marked. 
Evidences of neurasthenia were elicited in 101 of his 127 
patients. In 42 of 107 patients of all ages the nasal mucous 
membrane appeared to be normal {Revue de Laryngologie, Xos. 
7 and 8, 1895). 

PREDISPOSING AND AGGRAVATING CAUSES. 

Heredity and the temperaments classed as nervous are, 
strictly speaking, the predisposing causes. Broadly speaking, 
whatever diminishes the powers of resistance predisposes one 
to attacks. Most foreign substances that are liable to come in 
contact with the nasal mucous membrane will provoke parox- 
ysms, inasmuch as the mere contact of a polished silver probe 
will excite sneezing. Dust, pollen, infusoria; dry, hot air; cold, 
damp, or foggy air; smoke, gas, bright light from the sun, 
electric light, gaslight, sunlight reflected from snow, etc., are 
prolific causes. Much may depend on the character of the 
dust, for this is determined by the geological formation of any 
given locality. So wide is the distribution of dust by the vary- 
ing currents of the air that places which would naturally afford 
immunity from this disease may be visited by storms of noxious 
foreign pollen. A sea-voyage is considered a certain cure for 
an impending attack, but even there the enemy may lurk unseen 
in the folds of the canvas or clothing or in the upper currents 
of the atmosphere. Darwin has shown that pollen has been 
wafted many miles over the Atlantic. Showers of pollen have 
fallen hundreds of miles distant from its native soil. Dust 
may be deposited in curtains, carpets, etc., and be retained for 
indefinite periods before finding lodgment in the respiratory 
tract. The upper strata of the air may be laden with pollen, 
as it is at times with volcanic dust, which may be so dense as 
to darken the sky at great distances from the source of supply. 
These truths illustrate the omnipresent and occult character of 
the exciting causes. 



230 DISEASES OF THE EAR, NOSE, AND THROAT. 

The greatest suffering occurs from May to October, espe- 
cially in the country, and for the following reasons : At this 
season the air swarms with the fecundating dust of plants and 
flowers ; the dry, hot air of the country is not moistened during 
the day except by occasional rains ; the dry surface-soil affords 
the winds a never-failing supply of dust, and one is not pro- 
tected from the dazzling brilliancy of the sun by tall buildings 
in the country as he may be while pursuing the vocations of city- 
life. The streets of cities are deluged with water in summer ; 
the dust is laid ; the air is cooled and moistened by evaporation. 
Great buildings afford protection from the scorching rays of the 
sun. The denser the population, the less the vegetation and 
the greater the relief to asthmatics and hay-fever patients. 

The irritating effect of dry, hot air causes great activity of 
the muciparous follicles and imposes a heavy burden on the 
glands to pour out sufficient mucus to keep the membrane 
moist. One must avoid dry heat from stoves and furnaces. 
Much-thumbed books and newspapers that are a little musty 
are exciting causes that I have not seen mentioned. 



CHAPTER XXI. 

DISEASES OF THE NASAL CAVITIES, CONTINUED. 

Hay Fever, Concluded. 

Symptomatology. — A reciprocal relation exists between the 
capillary circulation of the skin and that of the internal organs, 
but more especially affecting the mucous membrane lining the 
air-passages. Let the surface of a hay-fever patient become 
chilled, the skin anaemic, the perspiration checked, and imme- 
diately there follow a corresponding hyperaemia of the mucous 
membrane of the respiratory passages, an increased activity of 
the muciparous follicles, exquisite tickling and painful itching 
in the nose and pharynx, succeeded by violent sneezing, profuse 
discharge of nasal mucus, suffused and tear-bedimmed eyes, 
photophobia, a rush of blood to the head and face, severe head- 
ache, complete occlusion of the nostrils, nervous exhaustion, and 
such a desperate shaking up of the whole being as is compar- 
able to a wrecked vessel in a terrific storm. But in this violent 
agitation of the body I have discerned a blessing in disguise, for 
it restores the balance of circulation to the skin, the tempera- 
ture rises, the sudoriferous glands resume their activity, and the 
skin is again bathed in perspiration. At this juncture the 
vicarious suffering of the respiratory surface is relieved and the 
normal equipoise of functional activity ensues. In one who 
suffers from the asthmatic form of hay fever, to the symptoms 
already enumerated should be added the characteristic symptoms 
of asthma proper. These alone make one's lot hard enough, 
but when added to the so-called " aristocratic " disease they 
present a highly-colored picture of the refinement of torture. 

The sneezing is often so violent and continuous that the 
patient is scarcely able to catch sufficient breath to properly 
oxygenate the blood. The hydrorrhea is so profuse as to satu- 
rate many handkerchiefs, — a dozen or a score in a day, in severe 
cases. One peculiar symptom I have observed, but have never 

(231) 



232 DISEASES OF THE EAR, NOSE, AND THROAT. 

seen mentioned by other writers is : the instant some patients 
begin to sneeze, they also swell up so that the clothes about the 
abdomen and waist must immediately be loosened to afford 
relief from the constriction. 

These attacks come on at precisely the same time and last 
the same length of time at each recurring season. A sudden 
mental excitement may prevent an impending paroxysm or 
abbreviate one after its onset. The attack is as instantaneous 
in its invasion as asthma, striking one at any moment of day or 
night, awaking one from sound slumber, or taking one unawares 
during the pleasant engagements of the day, and leaving as 
quickly and mysteriously as it came. 

Some functional nervous diseases are transmutable, one 
into another. I have witnessed cerebral hyperemia decline and 
disappear as hay fever superseded it, and after several years' 
duration the hay fever has, in turn, been displaced by asthma, as 
spasmodic and characteristic in its nature as the hay fever itself. 
Simple asthma may not only supplant, but may complicate it, 
constituting hay asthma proper. 

Inspection of the nasal cavities during attacks reveals the 
turbinated bodies enormously swollen and water-soaked, the 
mucous membrane very vascular, and the passages completely 
closed. The membrane is exquisitely sensitive and often pain- 
ful. In sleep it is necessary to breathe through the mouth, 
which occasions distressing dryness of the throat. The breath 
must be held while masticating or swallowing food, and with 
every act of deglutition the air is forced into the Eustachian 
tubes, and even particles of food seem to take the same course. 

In the intervals between the seasons of suffering, and even 
between paroxysms from day to day, the nasal membrane may 
present no unusual appearance. Indeed, just before a seizure 
the nostrils may seem more patulous than normal, affording 
perfect freedom of respiration. In some cases I have been 
unable to find any appearances whatever of a diseased condition 
between attacks. Others have the same hypertrophies that are 
common to other patients. 

There are considerable variations in the experiences of hay- 



DISEASES OF THE NASAL CAVITIES. 233 

fever sufferers, both with respect to their symptoms and the times 
of their attacks. It is very common for them to awaken in the 
morning feeling perfectly well, with the nasal passages comfort- 
able and free ; but the moment they arise and touch their bare 
feet to the cool floor, or feel the air strike the lower extremities 
or body, or even before rising, a few minutes of wakefulness are 
followed by sensations of dryness and irritation in the nose and 
miserable paroxysms of sneezing, as though they had taken a 
severe cold. The attack may last for a few minutes only, or 
until the morning meal with coffee, when all the symptoms sub- 
side. The attacks may re-appear at intervals during the day, 
with or without a feeling of rawness of the nasal membrane 
between the spasms of sneezing. 

Unlike the occasional sneeze of an individual who is not 
subject to hay fever, the act of sneezing is unaccompanied by 
any sense of pleasure or satisfaction. It is positively distressing, 
and makes the sufferer wretched. He is harassed by a con- 
sciousness of impatience and irritability of temper ; his muscles 
act in a jerky, inco-ordinate way, causing him to drop things or 
knock them together ; he must always be on the alert to avoid 
or escape those excitants of suffering that beset his path on 
every hand. 

The time these attacks usually come on is the 18th of 
August, but may vary from the 15th to the 20th in different 
individuals, although there is little, if any, variation in the case 
of any given patient. The season of suffering generally lasts 
until a severe frost occurs in September or October, when the 
season ends, and the refugees who have fled to the mountains 
or lakes of immune regions return to their homes to enjoy life 
until the following summer. In a small proportion of cases the 
attacks are more or less perennial. Exposure to sunlight 
reflected from snow, or to close, hot, impure or dusty air in 
winter, will result in suffering. Some are attacked in June or 
in July, when certain grasses ripen and the haying season is at 
hand. The presence of roses or certain other flowers may pro- 
voke sneezing at any season. 

Diagnosis. — Considering the characteristics and the descrip- 



234 DISEASES OF THE EAR, NOSE, AND THROAT. 

tion given, the matter of diagnosis is so simple as to require no 
further mention. 

Prognosis. — Hay fever is not dangerous to life, although it 
causes serious suffering and incapacitates one for business while 
it lasts. It does not tend to disappear of itself permanently, 
but is amenable to treatment. 

Abortive Treatment. — With the uric-acid phenomena in 
mind, I attempted to break up the morning attacks of sneezing 
and nasal stenosis by doses of acid at bed-time and on first 
awakening in the morning. The experiment was a success. 
A series of wretched mornings was followed by freedom of res- 
piration and a sense of well-being that seemed like a physical 
millennium. After this result of preventing the morning in- 
crease in the alkalinity of the blood, in order to prove the cor- 
rectness of my deductions, I used an alkaline treatment, and 
was both delighted and disgusted with the results. The old 
enemy raged again, but here was clinical proof of my first 
proposition. I have successfully repeated these experiments 
until I am satisfied of the correctness of these conclusions. 

The first acid I used for these experiments was the dilute 
sulphuric acid in doses of 20 or 30 drops in water, but, on 
account of the griping pains and diarrhoea that it produced in 
the early morning, I was obliged to substitute another. It 
occurred to me to try Horsford's acid phosphate that I had used 
for other purposes for some years, on the recommendation of 
the late Professor Jewell. I used teaspoonful doses of this 
without any ill-effects, and with the result of giving complete 
immunity from suffering. One or 2 teaspoonfuls in a glass 
of water at bed-time and on first awakening in the morning 
were sufficient to break up the habit entirely. In a few days, 
after the symptoms ceased to appear in the morning, this dose 
was omitted. The night dose was continued until the habit 
seemed to be entirely broken up. If any nasal irritation re- 
appeared, a dose or two would dispel it. By adding sugar to 
this acidulated drink it makes an agreeable lemonade, but it is 
better to avoid the sugar, and as much as possible all other 
uric-acid-producing substances. 



DISEASES OF THE NASAL CAVITIES. 235 

While I have depended on the mineral acids to keep down 
the morning alkalinity of the blood, Bence Jones claims that 
citric acid (lemonade) will accomplish the same result. I have 
made it a point to have the morning dose well diluted with 
water, for the purpose of starting perspiration, for I have ob- 
served that as soon as a patient has sneezed violently enough to 
produce free sweating the symptoms either decreased or disap- 
peared. The sweating carries off uric acid and helps to free the 
blood. 

I am aware of the differences of opinion that exist con- 
cerning the influence of an excess of dilute phosphoric acid on 
the elimination of uric acid, the effects of acid on the tubules of 
the kidneys, and the relation of a meat-and- vegetable diet to the 
formation of uric acid. I am careful to use only so much acid 
as is required to prevent the maximum of alkalinity from 
occurring. The acid is used not with the expectation of elim- 
inating, but of clearing the blood of uric acid, for the purpose 
of preventing attacks during the season of suffering. If the 
overwrought nerves are relieved of this source of irritation, 
they are much less likely to respond to other excitants; and, if 
the morbidly-susceptible condition of the nervous centres is due 
to the action of the uric acid, its oversensitiveness to all ex- 
citants may be relieved by correcting the uricacidaemia. After 
relieving the suffering with the acid phosphate I have produced 
it again by neutralizing the acid with an excess of bicarbonate 
of sodium and employing the usual doses. This converted the 
acid into a ready solvent of uric acid, flooded the blood with it, 
and produced the attacks. In turn, I have followed this up with 
the acid, relieved all the catarrhal symptoms by precipitating 
the uric acid from the blood into the tissues, and produced the 
characteristic gouty pains. Again, by substituting drachm 
doses of phosphate of sodium for the acid I have precipitated 
all the symptoms of a severe nasal catarrh. 

Some other remedies produce effects parallel to the acid 
treatment. Nitroglycerin, nitrite of sodium, nitrite of amyl, 
antipyrin, etc., have a similar effect. Opium raises the acidity 
of urine, diminishes the alkalinity of the blood, and reduces the 



236 DISEASES OF THE EAR, NOSE, AND THROAT. 






amount of uric acid. It relaxes the arterioles and improves the 
circulation of the brain. Iron and lead have a similar effect. 
Mercury reduces the excretion of uric acid, reduces tension of 
pulse, and produces diuresis. If opium is employed, its ill 
effects should be prevented by following up its use with salicylate 
of soda for a few days to free the system of uric acid. Quinine, 
so generally used, is contra-indicated, for, according to Quain, 
it brings uric acid into the blood. 

There is one remedy that has proved, in my hands, invariably 
unfailing in giving relief, especially when given at the beginning 
of an attack of nervous catarrh or common colds. It is for tem- 
porary use only, like the acid treatment. I have employed it 
for the last sixteen years or more, but in this case it is, like old 
wine, the better for age. I refer to a combination of atropia 
and morphia, in the proportion of 1 part of atropia to 50 of 
morphia. The ordinary adult dose is from -^ to | grain of this 
mixture, according to the severity of the attack. It may be 
repeated in an hour or two, if the first dose does not entirely 
relieve the sneezing, running at the nose, and stenosis. I do 
not believe it has ever failed to stop an attack when properly 
adapted to the case. No person has ever acquired the drug 
habit through my prescribing it. I never write a prescription 
for it nor allow a patient to know the composition of the 
remedy, — not for mercenary purposes, for I have more often 
given it away than I have charged for it, but in order to obviate 
the possibility of being responsible for a drug habit. The 
morphia clears the blood of uric acid, diminishes the nervous 
irritability, suppresses oversecretion from the muciparous glands, 
and stimulates the circulation and activity of the nervous centres, 
while the atropia elevates the tone of the blood-vessels, quickens 
the pulse, decreases all the secretions except the urine, sustains 
bodily temperature, stimulates the respiratory centre, counteracts 
the constipating effects of the morphia, and acts as an anti- 
spasmodic. Caffeine, I grain, may be added to this dose to 
stimulate the nervous centres and kidneys. 

Local Self-treatment. — The most useful self-treatment j 
have found is (1) the use of a*convenient pocket-inhaler (Fig. 



DISEASES OF THE NASAL CAVITIES. . 237 

128) that I have devised for patients who take cold easily. It 
is called the " camenthol inhaler." It can be used in an incon- 
spicuous and expeditious manner in public places, where it 
would be impracticable to combat a sudden seizure with other 
and slower measures. Several gentle, prolonged inhalations 
should be taken through one nostril while the opposite one is 
closed, until the irritation is relieved. The breath should not 
be allowed to pass back through the inhaler, but through the 
mouth instead. The camphor-menthol does not become irri- 
tating to the membrane, like menthol alone, after having been 
used a considerable time. It is blander and more soothing than 
the menthol crystals, iodine, or carbolic acid. When the throat 
is involved, it can be inhaled through the mouth for self-treat- 
ment. 2. For home treatment, morning and night, I usually 
prescribe a solution of camphor-menthol in lavolin, to be sprayed 
into the nostrils and throat. The 1- and 3-per-cent. solutions 
are the most satisfactory. It is best to begin witli the weaker, 
and increase gradually to the 3-per-cent. solution. 

Preventive Treatment. — The treatment to eliminate uric 
acid cannot be undertaken to advantage during the season of 
attacks, except so far as relates to diet and the use of lithia. 
Haig does not believe that excessive uric-acid formation takes 
place; but, from a considerable study of this subject, I am forced 
.to the conclusion that an excess of uric acid in the system is not 
due alone to continued retention and storage of the small normal 
overflow by the renal vein, but to an increased formation also. 
In a conversation with N. S. Davis, that eminent authority 
corroborated the latter view. It follows, then, that it is neces- 
sary to reduce as much as possible the use of those foods that 
increase the actual formation of uric acid, such as meats, sweets, 
beer, wine, etc., and limit the diet largely to fruits, vegetables, 
milk, fats, etc. 

Exercise also aids in the excretion of uric acid, although 
there may be an actual increase in the amount of acid. Lange 
treats periodical mental depression successfully by reducing the 
amount of food and by systematic exercise. 

A diet of milk with occasional very small quantities of egg 



238 DISEASES OF THE EAR, NOSE, AND THROAT. 

and fish, with no other animal food, will prevent suffering from 
sick headache entirely, without medicinal treatment. With this 
diet the natural ratio between uric acid and urea — 1 to 33 — is 
maintained. Haig claims that, by a uric-acid-producing diet, 
one can store up in the body several ounces of uric acid in a 
few years, or, by a correct diet, not as many grains. He has 
been on such a diet over eight years with very seldom a head- 
ache. By eating meat and drinking wine two or three days in 
any single week, he is sure to bring on the migraine. 

A course of salicylate, salicin, lithium, etc., will remove 
the excess of uric acid. If an alkali is given it is likely to pro- 
duce uricacidsemia and precipitate an attack of the trouble we 
are endeavoring to prevent. For an attack, then, a dose of acid 
should be given to free the blood of uric acid ; then the salicy- 
late of sodium should be given for two or three days or longer, 
to sweep it out of the body; but the salicylate should not be 
given during the attack, for it may aggravate the symptoms. 
For a fortnight or a month, perhaps longer, preceding the regu- 
lar season of attacks of nervous catarrh, from 2 to 6 grains of 
the salicylate should be given every day or two, in order to get 
and keep the quantity of the acid in the body down to the 
normal amount. The copious use of the stronger lithia-waters 
is advantageous, also. Warner's 3-grain tablets of effervescing 
citrate of lithia are excellent. 

This treatment, combined with proper diet, should be suc- 
cessful, provided that there is no organic disease of the struct- 
ures, central or peripheral. Any organic disease — hypertrophy, 
polypus, etc. — must receive such attention as to secure the 
harmonious co-ordination of their functions, for this treatment 
is directed against uricacidasmia only, as a cause of suffering; 
but it should not be forgotten that there are other causes that 
may operate to produce attacks, just as in the case of spasmodic 
asthma arising from bronchitis, irritating gases, and other 
excitants. 

I am of the opinion that, with this new theory, therapeutics, 
and proper diet of this disease, the medical profession need no 
longer say to hay-fever patients, in a patronizing way, " Suffer 



DISEASES OF THE NASAL CAVITIES. 239 

little children, for of such is the kingdom of heaven." But we 
must recognize and combat the uric-acid diathesis if we would 
bring comfort to these patients and obliterate a stigma that dims 
the lustre of our great art. 

^ MEDICAL OPINIONS. 

I have written to a large number of specialists and writers 
on this subject to obtain their latest views and treatment. There 
were some whose recent publications made it unnecessary to 
write, and others who were inaccessible ; so I have in such cases 
searched the literature and endeavored to present a fair and im- 
partial account of the present status of medical opinion on the 
nature and treatment of hay fever. From some articles I have 
been unable to gather any definite knowledge of the opinions 
of the writers on the nature of the disease, and have stricken 
out much for that reason, but I have, in every case presented, 
striven to give a natural and unbiased interpretation of the 
author's views. The methods of treatment often indicated 
these. The opinion of each writer on the pathology, whether 
he believes it to be a neurotic or local affection, is indicated by 
a single word following his name, — neurosis or local. 

E. L. Shurly. Neurosis. " I am very glad that yon will present 
the subject of the treatment of hay fever. It is a very important one, 
and does not receive the. intellectual attention which it deserves. It is 
my belief that some cases can be relieved by counter-irritation in almost 
any part of the bod} 7 , as well as in the nasal passages. I also believe 
that its purely nasal origin is overestimated. I have found snnn° of 
daturine with starch sometimes more effective than the galvano-eautery." 
He uses tincture of iodine, etc., over the neck and chest, as recommended 
by Faulkner. If there are new growths he removes them. 

W. E. Casselberry. Neurosis. " I believe ha} 7 fever to be amen- 
able to thorough surgical treatment, establishing a complete cure in a 
minority of cases only, — those particularly which present gross deform- 
ities of the septum and the turbinates, and potypi. In the large majority 
the condition can be materially mitigated, the degree of improvement 
being in accordance (1) with the degree of structural disease present in 
the nose and (2) with the thoroughness of the treatment. A small 
minority are not amenable to surgical treatment. They include the 
highly-neurotic individuals in whose noses, between the paroxj-sms, little 
or no structural change is apparent. Much can be accomplished toward 



240 DISEASES OF THE EAR, NOSE, AND THROAT. 

palliation b} T both systemic and local medicinal treatment. But in my 
experience medicinal treatment is nearly, if not quite, powerless to effect 
a permanent cure. Such, however, may take place in the course of years, 
perhaps, assisted b}- supportive and tonic treatment, as the individual's 
general health improves and the neurotic element lessens. Of local pal- 
liative remedies, cocaine is probabty the most powerful and at the same 
time the most dangerous remedy. Its use and sale should be regulated 
by law." 

C. H. Knight. Neiwosis. Destroys all enlargements. " When it 
is impossible to define a distinct abnormalit}^ the nasal membrane through- 
out being sensitive and irritable, good results seem to me to follow 
painting the mucous membrane with a solution of perchloride of mercury, 
muriate of quinine, and glycerite of carbolic acid. Of course, general 
treatment is alwa} T s essential. I must confess that my proportion of 
cures is small. I feel quite pleased if I succeed in mitigating the severit}^ 
of the sjmiptoms and lessening their duration, etc." 

W. C. Glasgow. Neurosis. " Surgical treatment has given little 
or no permanent relief. Symptomatic treatment will ameliorate the 
symptoms and keep the patients in comparative comfort during attacks. 
The Constitutional treatment with potassium iodide, belladonna, anti- 
pyrin, etc., lessens the disturbance and sometimes controls it." 

Jonathan Wright. Neurosis. " I have seen several cases with no 
appreciable intranasal lesion except the acute condition during the attack. 
I have operated a few times for intra-nasal lesions of various kinds. All 
were improved somewhat, — some markedly, some slightly. My im- 
pression is that the relief in these cases is too limited to make it of 
value." 

R. W. Seiss. Neurosis. " Operations in the nose should be re- 
sorted to cautiously, and only when absolutely necessary." He recom- 
mends strychnine and bromides internally, and benzoate of sodium, 10 
to 20 grains to the ounce, or menthol, 10 to 30 grains, for a spray. 

E. J. Kuh. Neurosis. A sufferer from hay asthma. He found the 
most relief from the following spray : Camphor, -J part ; menthol, 1 part ; 
creasote, 1 ; oil of eucalyptus, 2 ; oil of pine-needles, 2 ; albolene, 93J 
parts. 

J. O. Roe. Local. He believes that there is always a diseased 
condition of the nose causing hay fever. These diseased tissues must be 
removed or destroyed. He denies the neurotic character of the disease. 
He says : " Irritation reflected from other situations to the nasal cham- 
bers is not hay fever." 

F. H. Bosworth. Neurosis. He believes that intra-nasal surgery 
affords permanent relief. This method is clear in its indications, easy 
of accomplishment, and promises not only more immediate, but more 
permanent, relief than an}' other method. He believes that hay fever and 
spasmodic asthma are pathologically identical. 



DISEASES OF THE NASAL CAVITIES. 241 

J. N. Mackenzie. Neurosis. Better results were obtained from 
constitutional than from local treatment. He gives zinc, nux vomica, 
quinine, and arsenic. 

W. H. Daly. Local. He thinks it is simply a deformity in the 
nose, and that a large proportion of cases can be cured b} r surgical 
operations. 

J. Solts-Coiien. Neurosis. Any local nasal trouble maj r be simply 
incidental. He prescribes tonic treatment and restricts the use of meat. 

H. Gradle. Neurosis. He removes any nasal growths. 

Kitchen, of New York. Local. He believes it is due to the mem- 
brane being deficient in the epithelial covering, etc., that calls for local 
remedies. 

B. 0. Kinnear. Neurosis. He believes it to be due to irritation 
of the gray matter composing the centres of the fifth, glossopharyngeal, 
the facial nerves, and some of the pneumogastric. He found that treat- 
ment addressed to this condition was successful. He used the well-known 
ice-bags of J. Chapman, of Paris, along the spine between the shoulders, 
from the fourth cervical to the third dorsal vertebra, to dilate the 
arterioles of the whole body, thus evenly distributing the circulation and 
withdrawing the blood from the congested centres. The applications 
lasted from sixty to ninety minutes, one to three times a da}\ 

E. F. Ingals. Neurosis. About 40 or 50 per cent, of cases may be 
cured by cauterization. He gives tonics and uses cocaine locally. 

M. It. Brown. Neurosis. The supersensitive areas should be de- 
stroyed with the cautery. Atropine, T J F grain, once or twice daily or a 
4-per-cent. solution of cocaine locally may give temporary relief. 

H. II. Curtis. Neurosis. He sears the enlarged tissues with 
chromic acid in preference to all other escharotics. 

C. E. Sajous. Neurosis. He believes that if cauterization fail to 
cure, it is because it is not carried deeply enough. He uses glacial acetic 
acid or nitric acid. He gives strychnine and coca-wine after meals. 

Willtam Cheatham, of Louisville. Neui^osis. He praises anti- 
P3'rin in 10 to 30 grains ; also acetanilid, 4 to 6 grains a day. 

T. M. Hardie. Neurosis. He believes that operations will benefit 
a large proportion, but constitutional treatment is necessary in most 
instances. 

J. It. Davey. Neiwosis. He removes enlargements and gives 
potassium iodide and tonics. 

Beverly Robinson. Neurosis. Soothing applications and con- 
stitutional medication. He advises against surgical interference except 
when there are positively-diseased growths. 

I. Gluck. Local. He believes the nervous element to be a result, 
instead of the cause, of the disease. He uses a 10-percent, solution of 
atropine after anaesthetizing with cocaine-phenol. He gives aconitine 

16 



242 DISEASES OF THE EAR, NOSE, AND THROAT. 

every hour or two, affording relief and aborting attacks in from two to 
five days. 

Carl Seiler. Neurosis. He uses sprays of cocaine and plugs of 
cotton saturated with it. A sponge worn in the nose to filter the air is 
recommended. Quinine in large doses is advised and tonics and atropine 
for the fever. In the later stages iodide and bromide of sodium are 
given. Morphine hypodermatically is advised. All enlargements should 
be removed ; he gives dilute phosphoric acid, 30 drops a day. 

De Lamalleree. Neurosis. He believes it a neurosis of nasal 
origin, and claims to subdue morbid sensitiveness of the membrane by 
douches of carbonic-acid gases locally for fifteen minutes at a time, three 
times a day. 

Sir Andrew Clark. Neurosis. He resorts to constitutional 
remedies and applies to the nostril with a camel's hair pencil this mixt- 
ure : 1 ounce each of glycerin and carbolic acid, 1 drachm of quinine, 
and soVff P ar * °f tDe perchloride of mercury. Heat must be used to 
dissolve the quinine. 

P. McBride. Neurosis. He treats it as a nervous disease, and if 
this fail he uses cocaine and the galvano-cautery. He deprecates indis- 
criminate burning, however. 

D. B. Lees. Neurosis. He claims to abort it with bromide and 
belladonna. 

Gouguenheim. Neurosis. He uses nervines and cocaine locally. 

The author operates with the galvano-cautery or by other methods 
when there are positive indications for such measures. 



Plate III 



PLATE III. 

Figure 1. — Female, set. 23; posterior view of large posterior hypertrophy of left in- 
ferior turbinated body ; removed with snare. 

Figure 2. — Female, get. 26 ; hypertrophy of middle and inferior turbinated bodies, 
both sides, causing bilateral stenosis ; removed with snare. 

Figure 3. — Complete occlusion of both nasal cavities by hypertrophies, complicated 
with adenoid vegetations of the vault. 



Figure 4. — Lateral section of larynx and pharynx ; g, Section of mass of hypertro- 
phied adenoid tissue of the naso-pharynx seen in Fig. 6 (uvu]a cut off). 

Figure 5. — Anterior section of above, showing relation between nasal cavities and 
the larynx. (The vocal bauds in the latter are in the cadaveric position.) 

a, Superior turbinated bone. e, Junction of the hard with the soft 
6, Middle " " palate (the latter being cut off). 

c, Inferior " " g, Anterior portion of the pharyn- 

d, Orifice of Eustachian tube. geal vault or posterior nasal cavity. 

p, Posterior aspect of septum. 

Figure 6. — Posterior section of pharynx, showing mass of hypertrophied tissue in the 
posterior portion of the pharyngeal vault, as seen in a patient in whom congenital absence 
of the uvula existed. 



Figure 7. — Posterior view of left cavity in atrophic rhinitis. 

8.— Lateral 

9.— Anterior " " " " " 

10. — Rbinoscopic view of left cavity ; " " 

11. — " " " " mirror slightly turned. 

12. — Microscopic section of the mucous membrane in atrophic rhinitis. 



[Note. — The Nos. 4, 5, and 6 had to be shortened one inch from below the Eusta- 
chian prominences so as to enable them to be represented. The other proportions are 
accurate.] 



te ill 




t Sajous, Pinxit 



£ur«&M c Fetr,dge,L<z 




Fig. 130.— Nasal Synechia. (Author's specimen.) 

Point of probe is inserted between the inferior turbinated body and the projection 
of the septum at the point of their union. 




Fig. 131.— Posterior View of Osseous Bridge Shown in Fig. 130. 
(Author's specimen.) 



CHAPTER XXII. 
DISEASES OF THE NASAL CAVITIES, CONTINUED. 

Hypertrophic Rhinitis. 

Pathology. — In this form of nasal catarrh there is not only 
a thickening of the mucous membrane, but also an increase of 
connective-tissue formation in the submucous layer, or corpora 
cavernosa. The venous sinuses, having passed through the 
stage of vasoparesis, have now become permanently dilated. 
The newly-formed fibrous tissue prevents their contraction and 
maintains them rigidly dilated until pressure upon their walls 
by contraction of this tissue, the presence of leucocytes, or the 
formation of connective-tissue septa and thrombi within the 
sinuses finally obliterates them. 

During the hypertrophic stage there is increased vascularity 
of the turbinals and of the septum. The most frequent situa- 
tions of thickening of the membrane and tissues beneath are 
the posterior ends of the turbinate bodies (Plates II and III). 
Depressions and spurs of the septum nasi, ecchondroses and ex- 
ostoses, and deflections resembling corrugations are frequent 
accompaniments (Plate V). Occasionally adhesion occurs be- 
tween the septum and turbinals, forming a bridge, or synechia 
(Figs. 130 and 131). 

Etiology. — This is a sequel of simple chronic rhinitis. 

Symptomatology. — The obstruction to the free passage of 
air through the nose, by the great thickening and deformities of 
the turbinals and the septum, causes partial or complete mouth- 
breathing. Patients complain that they take cold easily and 
that when lying on the side the lower nostril closes. The latter 
symptom occurs in consequence of the blood gravitating to the 
lower turbinals and causing them to swell. A slight exposure 
results in stenosis of both nostrils, and as a result the constant 
passage of air through the throat instead of the nose dries the 

(243) 



244 DISEASES OF THE EAR, NOSE, AND THROAT. 

throat and larynx and gives rise to more or less irritation or 
inflammation of these parts. 

When the stenosis is marked the nasal voice is a charac- 
teristic sign. Invasions of the nasal dncts and Eustachian tubes 
lead to involvement of the conjunctivae and the middle ears. 
Watery eyes, impairment of hearing, and tinnitus aurium are 
common sequelae of this disease. When the very young are 
affected the pharyngeal and oral tonsils are often found hyper- 
trophied (Plates II, III, and V) and require excision. Anosmia 
(absence of the sense of smell) and impairment of taste are 
occasional symptoms. When headaches are present, they are 
referred to the supra-orbital or frontal region. 

Asthmatic attacks are sometimes due to pressure of the 
enlarged turbinals against the septum. The secretions, which 
are much more abundant than in health and more copious in 
the morning on account of their accumulation during the 
sleeping-hours, cause a disagreeable habit of hawking and 
hemmiug to clear the throat, especially on rising in the 
morning. 

Diagnosis. — The septum, like the turbinals, is red and 
thickened, particularly near its base. The turbinals, instead 
of presenting a smooth, glassy surface, as in the simple form, 
are hypertrophied unevenly and sometimes present a somewhat 
nodular appearance. The inferior turbinate body usually shows 
the greatest enlargement, but the middle one is often found in 
contact with the septum. Their posterior extremities may blos- 
som out into berry -like buds of a gray or purple color (Plates 
II and III). The former are the commoner. Probe-pressure 
meets with a firm, instead of a fluctuating, resistance. 

Prognosis. — After middle age the hypertrophies generally 
are absorbed and disappear, when this form often becomes 
merged into atrophic catarrh. The hearing is likely to suffer, 
and there is a strong predisposition to catarrhal affections of the 
pharynx and larynx. Modern methods of surgical treatment 
afford an excellent prognosis. 

Treatment. — Cleanliness is the first essential in this as in 
other forms of nasal catarrh. The solutions and methods given 






DISEASES OF THE NASAL CAVITIES. 245 

in treating of the simple form are indicated here, but medicinal 
treatment alone will not suffice to remove hypertrophies. Oper- 
ative measures must be brought into requisition. Of these the 
galvano-cautery is now the most frequently resorted to except 
for cartilaginous and osseous outgrowths, which require the 
knife, the saw, or the drill. For the fibrous growths the hot or 
cold snare, scissors, chemical caustics, etc., are employed. We 
will first consider the electrical apparatus. 

For physicians who practice in the country, where the 




Fig. 132.— Flemmi>~g Cauteky Battery. 



incandescent electric lights are not a part of their office equip- 
ment, the Flemming cautery battery (Fig. 132) is satisfactory. 
It has the advantage of the pedal mechanism, which prevents 
the immersion of the zinc and carbon elements in the cautery 
fluid except when in actual use. This extends the life of the 
battery very materially. It has one fault, — that of permitting a 
slopping over of the fluid, which is destructive to carpets or 
Mosaic floors. The author has remedied this by having a 
rubber hydrostat constructed that effectually overcomes this 



246 DISEASES OF THE EAR, NOSE, AND THROAT. 

defect. By keeping a fresh supply of the fluid on hand, one 
need never be disappointed by the battery not working. 

If the physician's office is wired for incandescent electric 
lights, or if he is not remote from conveniences for storing his 
battery, the one shown in Fig. 133 is to be recommended. It is 
more easily portable than the fluid battery, and will give a white 
heat if desired. Unlike the fluid battery, it deteriorates in con- 
sequence of disuse, and is better for being worked at least three 



Fig. 133.— Trtjax Storage Battery. 

times a week. When lying idle it sulphates ; that is, sulphate 
of lead forms on the plates and renders it inoperative. 

Figs. 134 and 135 show several of the most useful cautery 
electrodes, and Fig. 136 a convenient handle. One must select 
the electrode according to the individual characteristics of each 
case. 

If the physician does not happen to have the conveniences 
of the electro-cautery, he may resort to chromic, or nitric, or 



DISEASES OF THE NASAL CAVITIES. 



247 



monochloracetic acid. Of these the chromic acid possesses de- 
cided advantages over the others. It is fusible into an easily 
manageable bead on the chromic-acid applicator (Fig. 66). To 
accomplish this, the platinum loop is dipped into the dry acid 



Fig. 134.— Cautery Electrodes. 



crystals and held over a small flame to heat. As soon as the 
acid begins to melt it is quickly removed from the flame and 
blown upon to cool it rapidly into the form and size of bead 
desired. One should be careful not to apply the acid on a very 



» ^^_ ^ 



Fig. 135.— Cautery Knife. 



moist surface too long, or sufficient moisture will be rapidly ab- 
sorbed to loosen the bead and allow it to fall off the loop, and 
thus cauterize tissue that does not need it. In the use of liquid 
acids all the surplus fluid must be pressed out of the cotton 




Fig. 136.— American Cautery Handle, with Windlass. 
It answers for snaring as well as for holding electrodes. 

pledget by which it is applied before introducing it into the nose, 
otherwise it will spread over the surrounding surface. 

Ten or fifteen minutes before cauterizing the mucous mem- 
brane a 10-per-cent. solution of cocaine hydrochlorate is to be 



248 DISEASES OF THE EAR, NOSE, AND THROAT. 

applied. It must not be sprayed into the nose, for toxic effects 
and collapse may result from an overdose. It is best to twist a 
piece of absorbent cotton loosely on the carrier (Fig. 9), dip it 
into the cocaine solution, and then adjust it nicely to the 
particular area we desire to cauterize and blip it off the carrier, 
leaving it pressed between the septum and turbinals. Like the 
liquid acids, the surplus of cocaine solution should be pressed 
out in the mouth of the medicine-container before introducing it. 
The patient is directed not to swallow any that may trickle into 
his throat. In about ten or fifteen minutes the membrane 
should be sufficiently anaesthetized to burn without pain. It 
need hardly be repeated that the membrane must be thoroughly 
cleansed before the treatment, for if thick discharges are present 
they prevent the action of the drug upon the tissues as well as 
weaken it by dilution. 

I find it useful to instruct the patient to raise his hand if 
he should begin to experience any severe pain from the cautery. 
However, by employing a strong preparation of cocaine and 
leaving it a considerable time, even twenty minutes, in contact 
with the membrane by means of the cotton pack, it is possible 
to burn deeply without causing much discomfort. There is an 
advantage in cauterizing deeply. As cicatrization takes place a 
furrow forms, which, together with the subsequent contraction, 
leaves a capacious breathing-space between the turbinate body 
and the septum. 

The electrode must not be allowed to cool while in contact 
with the tissue, for if it does it tears away the burned parts 
during the removal, and leaves a raw, unprotected, bleeding- 
surface. It must be removed while it is still hot, care being 
taken to avoid touching any but the cocainized spot. If the 
electrode is permitted to touch the border of the naris in its 
withdrawal, the resulting burn will cause much annoyance. 

Only a small area should be cauterized at one treatment. 
Not more than one-third or less of the turbinate body should be 
treated to a single cauterization, for if more is included the reac- 
tion occasions considerable swelling, a copious serous discharge, 
pain, headache, irritation of the corresponding eye, and even 



DISEASES OF THE NASAL CAVITIES. 249 

tumefaction and discoloration of the cheek and loose areolar 
tissue of the lower eyelid. It is generally best to allow about 
a week to intervene between cauterizations of the same side, 
but when patients from a distance can remain but a brief period 
the opposite nostril can be burned in about four or five days 
after the first, if the burned areas are not too extensive. 

After each cauterization the most satisfactory results are 
obtained by introducing a packing between the burned surface 
and the septum, consisting of a pledget of cotton moistened 
with a 20-per-cent. solution of camphor-menthol in lavolin. 
The packing is only large enough to cover the cauterized area, 
and not enough of the solution is used to press out and run 
from the nose. This is exchanged for a fresh dressing daily for 
four or five days, when the tissues will appear shrunken and 
mummified instead of swollen, succulent, and covered with a 
slough, as they do without this method. Under the treatment 
outlined there is little or no haemorrhage, pain, or reaction, but 
the parts pursue a placid course to recovery. For headaches 
due to intra nasal irritation, and especially to middle turbinate 
pressure, Ilanau W. Loeb uses cocaine and albolene sprays. He 
advocates correcting all nasal abnormalities that may be a source 
of irritation. 

The use of the cautery is really a simple operation, but 
care must be exercised to not approach too near the orifice of 
the Eustachian tube. I have seen acute suppurative inflam- 
mation of the middle ear result from such procedures. Seiss 
(TJierapeiUlc Gazette, November 15, 1894) cites cases of ear 
disease made worse by nasal treatment. The membrane being 
cocainized, a speculum is introduced and the light from the 
forehead-mirror is thrown into the nostril. The chosen elec- 
trode is introduced cold and placed on the anaesthetized area, 
when the current is turned on sufficiently to give a bright-red 
glow. If the patient evince pain, or if the electrode is seen to 
burn as deeply as is desired, the current is interrupted and at 
the same instant the electrode is moved outward so as to part 
from the tissues before cooling. If the whole lower turbinal is 
hypertrophied, the anterior third is cauterized first and at inter- 



250 DISEASES OF THE EAR, NOSE, AND THROAT. 

vals of about a week the contraction and consequent opening 
will be sufficient to admit of treating the middle and posterior 
thirds. 

Unless the camphor-menthol packing is used, swelling 
occludes the passage until about the fourth or sixth day, when 
the slough separates. When the cauterization is extensive or 
deep, some considerable pain may be experienced for a number 
of hours, unless a pledget of cocainized cotton is left covering 
the surface. Occasionally a little pain is experienced in the 
upper incisors. If the septum is not hypertrophied the electrode 
should be kept pressed away from it, and the burning is not 
carried deeply enough to include the periosteum. 

On the days following cauterizations the nose is sprayed 
with the alkaline antiseptic solutions already mentioned, and 




Fig. 137.— Hobby's Steel, Snare. 



then by a 4-per-cent. solution of eucalyptol in lavolin, or the 
same strength of pine-needle oil, or benzoinated lavolin. 

For posterior hypertrophies Seiss prefers curettement. The 
snare (Fig. 137) is preferred by many specialists. It is intro- 
duced with the loop open, as shown in Fig. 136, and passed 
over the enlargement so as to engage it as near its base as pos- 
sible, when, by drawing upon the handle or turning the wheel, 
the loop is made to sever the tissues. The Jarvis transfixing 
needle facilitates this maneuvre. The needle is passed through 
the hypertrophy until it projects beyond ; the snare-loop is passed 
over both ends of the needle so as to lie on its under surface 
and to cut between the needle and the base of the growth. The 
cutting is done by a turn of the wheel at a time, taking from 
one-half to an hour for the operation. The more time, the less 



DISEASES OF THE NASAL CAVITIES. 



251 






blood. In removing posterior growths the rhinoscopic mirror 
is required, in order to view the field of operation. 

When deformities of the cartilaginous septum necessitate 
their removal, this is best accomplished by means of a specially 
fashioned knife having a tapering point (Fig. 138). After 
cocainizing, the hypertrophy is severed by entering the blunt 



truax cbeeme8c0 
Fig. 138.— The Author's Septum-knife. 



point of the knife below and cutting upward. In this manner 
the occlusion of the field by haemorrhage is avoided if the cutting 
is done rapidly. 

Exostoses are sawed off in a like manner (Fig. 139). The 
motion of the saw should be rapid, and one should not bear too 
hard upon the handle so as to make the saw catch and stick. 




Fig. 139.— Webster's Nasal Saws. 



With practice one can work rapidly w T ith this instrument. The 
electric drill is a very efficient instrument and is manipulated 
like a dentist's drill. 

Hygienic measures and internal treatment must be em- 
ployed according to the indications and on general principles, 
and the matter of clothing is touched upon in the treatment of 
acute rhinitis. 



252 DISEASES OF THE ear, nose, and throat. 

Atrophic Rhinitis. 

Synonyms. — Ozsena ; fetid catarrh ; cirrhotic rhinitis, etc. 

Pathology. — This form of nasal catarrh is a sequel of a pre 
existing* inflammation ; indeed, it may he said to he the third 
stage of rhinitis in the logical order in which we have treated 
of the subject: (1) simple rhinitis, (2) hypertrophic rhinitis, 
and (3) atrophic rhinitis. In the latter variety there occurs an 
absorption and contraction of the newly-formed connective 
tissue, obliteration of the venous sinuses, and atrophy of the 
mucous membrane (Plate III). The turbinate bodies are 
reduced by this sclerotic process to less than their normal cali- 
bre, and the nasal cavities are correspondingly increased in size. 
The mucous glands participate in the general cirrhotic condition 
and exude less secretion, which leaves the membrane dry ; or 
the mucus becomes dried into scales or crusts, which decompose 
and emit a foul odor. The latter condition is not always 
present, and is probably dependent upon a strumous diathesis. 

Etiology. — This is generally a sequel of a chronic rhinitis. 

Symptomatology. — In most cases of atrophic rhinitis the 
nasal membrane is of a very pale color and is dry in appear- 
ance. The lumen of the passages is enormously increased, so 
that one can see through to the throat. One or more of the tur- 
binals may remain somewhat hypertrophied, indicating the pre- 
vious condition, while the others are shrunken into miniatures 
of the normal bodies. On account of the dilatation of the cavi- 
ties the patient is unable to bring sufficient air-pressure to bear 
to dislodge the drying secretions, and they are permitted to stick 
fast until decomposition renders them fetid and indescribably 
odoriferous. In this form, or ozaena, smell is lost — a beneficent 
provision — and taste is impaired, and sometimes the hearing 
also. A muco-purulent discharge is often found in such cases, 
and this, on drying into crusts, presents a green or dark-brown 
color. 

Diagnosis. — This is not difficult, for the appearance of the 
parts in the simple atrophy and a smell of the sickening, dis- 
gusting fetor of ozaena are distinctly characteristic. Suppura- 



DISEASES OF THE NASAL CAVITIES. 253 

tion of the accessory cavities is generally unilateral. In syphilis 
necrotic bone may he detached with the probe, or the bridge 
may become depressed and the septum eroded away. 

Prognosis. — As this disease is usually found between pu- 
berty and the thirty-fifth year only, it may be expected to dis- 
appear in time of itself; but its disgusting character, as much 
as its possible deleterious effect on the patient's general health, 
calls for persistent treatment. This must be measured by 
months, and it may take a year or more to eradicate the ozoena; 
but this can be done. 

Treatment. — In the simple, dry, non-odorous atrophy stim- 
ulating applications, — like a 4-per-cent. solution of iodine in 
lavolin, — fumes of resublimed iodine crystals from the infiator 
(Fig. 24), and gentle massage of the parts with the smooth probe 
will increase the circulation and nutrition. Norval H. Pierce 
speaks of the vibratory-massage treatment as follows: "After 
thoroughly testing* Braun's vibratory massage in Chiari's Vienna 
clinics, one of my conclusions was that to the cleanliness which 
is so essentially a part of this mode of treatment is due most of 
the speedy reliefs of disagreeable symptoms, — fetid secretions. 
Braun claimed that under his treatment the atrophic turbinated 
bodies returned to their natural proportions. My experience 
has not substantiated this latter statement. During the past 
year I have modified Braun's methods in the following manner: 
The patient comes to me daily. A piece of absorbent cotton 
loosely pulled from the roll is torn to a size which will 
completely, but loosely, fit the inferior meatus and space in- 
cluded between the middle of the inferior turbinated body and 
septum. This dry cotton is held in the holder and the vi- 
bratory movements are carried over the mucous membrane of 
the inferior, middle, and superior turbinated bodies, pharynx, 
meatus (as far as possible), septum, and floor of the nose. 
From three to six pledgets of cotton may be necessary in each 
nostril to entirely bring- away the discharge, scabs, etc. This 
absolute cleanliness cannot be too strongly insisted on. On 
examination after this massage the mucous membrane looks 
pink and clean, and the patient often experiences a feeling of 



254 DISEASES OF THE EAR", NOSE, AND THROAT. 

comfortable warmth and relief in the nose. Immediately after- 
ward we may use balsam of Peru, 10-per-cent. iodoglycerin, 
thymol in albolene, or any of the many good things recom- 
mended for the disease, provided they are not too irritating. 
But I am convinced that the vibratory massage, carried forth 
as above described, has a distinct worth, and will shorten the 
treatment of fetid rhinitis by many months." 

Brown, Dionisio, and Laker {Journal of Laryngology ; 
1894) advocate intra-nasal vibratory massage by stroking and 
vibration with hand or electric cotton-covered probes. 

For the ozsena, washes of an alkaline, antiseptic character 
must be copiously used to free the cavities of all decomposing 
masses. The nasal douche so often advised is mentioned only 
to condemn, on account of the possibility of damaging the Eusta- 
chian tubes and ears. Seiler's solution is excellent and should 
be thrown in a coarse spray until all the crusts are loosened 
and expelled, leaving a free, clean membrane to receive the 
curative medicaments. Listerin, glycothymolin, and micrazotol 
are excellent, despite their names. The latter contains boroglyc- 
eride, eucalyptol, thymol, resorcin, menthol, and benzoic acid. 

The patient should be given a wash to use morning and 
night, after which he should spray the nostrils and throat thor- 
oughly with a 3-per-cent. solution of camphor-menthol in lavo- 
lin. Two or three times a week the surgeon, after cleansing the 
cavities, should spray them with such remedies as carbolic acid 
and iodine in lavolin (4 per cent.), and then dust the membrane 
all over with aristol powder (Fig. 32). When the odor is 
very foul the powder application should be preceded by a spray 
of a 10-per-cent. solution of camphor-menthol in lavolin. 

Tonic and alterative constitutional treatment and hygienic 
measures must be resorted to on general principles. 



CHAPTER XXIII. 
DISEASES OF THE NASAL CAVITIES, CONTINUED. 

Epistaxis. 

Synonyms. — Nose-bleeding ; nasal haemorrhage ; haemor- 
rhagia narium. 

General Considerations. — Bleeding from the nose may 
have its origin in the nasal cavities proper or in the adjoining 
sinuses. It is frequent in childhood, occasional in old age, and 
rare in middle life. 

Pathology. — The bleeding-point is most often found on the 
side of the septum, near the floor, and adjacent to the opening 
of the nose. Vessels may, however, rupture in any part of the 
membrane, or the haemorrhage may proceed from one of the 
accessory cavities. Probably the bleeding occurs most fre- 
quently from ulceration of the membrane, by means of which 
the blood-vessels are penetrated by an extension of the erosion 
to their walls. This process perforates the septum ; crusts form 
on the ulcerating parts, and upon their removal a raw, bleeding 
surface remains. 

Etiology. — Falls and blows, the bad habit of picking the 
nose, foreign bodies, fractures, vicarious haemorrhage, purpura 
haemorrhagica, etc. , cause nasal haemorrhages. 

Symptomatology. — Bleeding may come on without any 
premonitory symptoms, and even during sleep. The blood 
usually trickles from one nostril, a drop at a time, but sometimes 
runs in a stream. Only a slight amount is lost ordinarily, but 
it may amount to an alarming quantity and may even prove 
fatal. Frequent haemorrhages tend to produce anaemia and 
demand corrective measures. 

Diagnosis. — The condition is usually made out without 
difficulty. 

Prognosis. — This is ordinarily good, but in old age it 
may be indicative of degeneration in the walls of the blood- 

(255) 



256 DISEASES OF THE EAR, NOSE, AND THROAT. 

vessels. In low fevers and diphtheria it is an ominous 
symptom. 

Treatment. — The most common means adopted to check 
bleeding from the nose is to keep the head upright and com- 
press the nostrils with the thumb and forefinger, or apply cold 
to the nose or the back of the head and spine. Hot water is 
recommended by some to be applied to the nose or injected into 
the bleeding nostril. The ice-bag (Fig. 78) is a convenient 
means of using continuous cold. Pulverized alum and tannin 
are useful. The latter is used in powder or, as mentioned later, 
in connection with tampons. A 10-per-cent. solution of cocaine 
on a cotton pledget packed firmly between the bleeding-point 
and the opposite wall is effective. 

It is sometimes difficult, even with good reflected light, to 
locate the source of haemorrhage, but this should be accom- 
plished if possible. Antipyrin in 3-per-cent. watery solution or 
in powder and the liquor ferri perchloridi are useful. Some 
writers speak highly of the galvano-cautery, but I cannot 
indorse it for this purpose. 

If the simpler measures fail, resort must be had to tampons! 
I have found the following method the most efficacious : A long 
strip of lint, linen, or cotton cloth, three-eighths of an inch (one 
centimetre) wide, is immersed in a saturated solution of tannic 
acid in water, and then the water is pressed out, leaving the 
cloth thoroughly medicated. One end of this is carried by the 
delicate angular forceps or probe as far into the nose as the 
case requires. Then the remainder of the tampon is packed in, 
a small loop at a time, until it is pressed firmly into all the 
sinuosities, and the cavity is completely filled. Any surplus of 
the strip is then cut off. 

Should tamponing of the anterior naris fail, posterior 
plugging must be added to it. In this case the posterior nares 
must be plugged first, as follows: Bellocq's cannula (Fig. 140), 
is threaded through the eye in the end of the spring with a 
strong string. The thumb-screw is adjusted so that it will 
throw the spring out, as shown in the cut. Then the sound 
is introduced like the Eustachian catheter until the distal 



DISEASES OF THE NASAL CAVITIES. 257 

extremity projects downward over the velum palati. At this 
moment the spring is extruded until it, with the string, is seen 
through the open mouth. With hook or forceps one end of the 
string is brought out of the mouth and a pledget of cotton or 
lint as large as an adult's thumb is tied firmly to it. This is 
drawn backward and upward through the mouth and throat 
into the posterior nares. It should be made to plug effectually 
both posterior nares, for otherwise haemorrhage might continue 
through the free one. In passing the tampon behind the 
palate, the finger should be introduced to prevent drawing the 
palate upward with the cotton. Then the finger can pack the 
tampon well into the nares. The string protruding from the 
anterior naris is fastened back of the ear with adhesive plaster. 
In hot weather this must be watched, or the perspiration will 




Fig. 140.— Bellocq's Cannula Introduced. 

loosen it and allow the tampon to become displaced or swal- 
lowed. After a day or two the packing must be removed to 
prevent septicaemia. In the absence of Bellocq's cannula the 
Eustachian catheter can be substituted, and I have succeeded 
with a silver male catheter in an emergency. 

Constitutional treatment may be required, — iron, ergot, etc. 

Nasal Polypi. 

There are three varieties of benign neoplasms to which 
the term " nasal polypi " is applied : mucous, fibrous, and 
cystic. 

MUCOUS POLYPI. 

These occur in multiple form, and sometimes they -are 
very numerous (Plate IV). They are a pale-pink or ashy- 
gray color, and are most troublesome in damp weather, when 






258 DISEASES OF THE EAR, NOSE, AND THROAT. 

they absorb moisture, causing them to swell and occupy in- 
creased space. They are usually found in middle life, from 20 
to 40 years, and occasion stenosis of the nares and mouth- 
breathing (Fig. 148). The mucoid variety is the most com- 
mon. Patients often observe movements in these polypi, which 
are occasioned by forcible currents of air in sniffing or blowing 
the nose. 

FIBROUS POLYPI. 

This variety presents a single, dense, resisting surface to 
the probe. It may develop into so large a mass as to invade 
the naso-pharynx (Plate IV) or project from the nostril. It 
causes stenosis and supra-orbital headache, and its expansion 
causes pressure and deflection of the septum, as well as absorp- 
tion of the turbinals. Necrosis of the bones and invasion of 
the adjacent sinuses may occur. The nose in some cases is 
bulged outward at the sides, which gives the arch a flattened 
appearance. 

CYSTIC POLYPI. 

These are very rare, and consist of a cyst or sac filled with 
a yellowish or bloody, serous fluid. 

Treatment. — Polypi should be removed preferably with the 
cold-wire snare (Fig. 137). The loop of the snare is intro- 
duced expanded, as seen in the electric snare (Fig. 136), and 
made to embrace the pear-like tumor and to slide up to its 
attachment. The polypus is then slowly cut off and the point 
of attachment is cauterized with the galvano-cautery or chromic 
acid to prevent a return of the growth. This is preferable to 
removal with the forceps or scissors, and if the evulsion is 
not too rapidly accomplished little haemorrhage ensues. The 
biting curette (Fig. 141) is serviceable for searching out and 
removing the mere buds of polypi in the upper nasal passages. 
After-treatment is the same as after removal of hypertrophies, 
already given. 

Papillomata. 

These are benign neoplasms of infrequent occurrence. 
They may be single or multiple, and are most often attached to 



DISEASES OF THE NASAL CAVITIES. 259 

the lower part of the septum or inferior turbinal. (See " Treat- 
ment " under " Erectile Tumors.") 

Erectile Tumors. 
These are very rare. They have the appearance of an 
hypertrophy of the turbinate body, except that pulsation can be 




Fig. 141.— Bitixg Curette. 



detected in them. This is in consequence of their close relation- 
ship to an artery, and their removal is likely to be attended with 



considerable haemorrhage. 



Treatment consists in removal of the growths either by 
chemical or mechanical means. Chromic acid or the galvano- 




Fig. 142.— Casselberry's Saw-tooth Scissors. 

cautery may suffice, or the nasal scissors (Fig. 142) may prove 
preferable. 

Chondromata. 

Cartilaginous tumors are rare growths occurring about the 
age of puberty and springing from the septal cartilage. Their 
location, unyielding firmness, and sessile shape distinguish them 
from fibromata. The color is a light pink, and they have not 



260 DISEASES OF THE EAR, NOSE, AND THROAT. 

the smooth surface of fibrous tumors, but are indented by 
numerous depressions. 

Treatment. — If these growths prove troublesome they 
should be removed. Many methods are in use, — the knife, 
saw, chisels, punch, dental or electric drills and trephines, the 
galvano-cautery, etc. 

The cartilaginous growth is easily removed, under cocaine, 
by the author's septum-knife (Fig. 138). The cutting should 
be done as already described, and care must be taken not to 
perforate the septum. It is claimed by some rhinologists that 
healing does not take place so readily after the galvano-cautery 
as after cutting, but I have not been able to confirm this 
opinion. 

OSTEOMATA. 

The bony tumors are also very rare. They are offshoots 
from the mucous membrane and the product of an osseous 
degeneration of connective tissue. Their pressure produces 
headache, occasional haemorrhage, and ulceration with a puru- 
lent discharge. Unlike rhinoliths, they resist a needle and do 
not crumble. (See " Treatment " under " Exostoses.") 

Exostoses. 

Osseous growths are frequently met with in the nose. They 
usually take the form of ridges or spurs upon the bony septum, 
encroaching upon the lumen of the passage sometimes to a con- 
siderable extent. Occasionally the growth attains to consider- 
able proportions until pressure is produced on the opposite 
turbinal or adhesion to it occurs, forming a synechia or bridge 
across the canal. Figures 130 and 131 show such a condition. 
In Fig. 130 the probe is inserted to the point of adhesion 
between the exostosis and the inferior turbinate bone. The 
contour of the latter will be seen in Fig. 131 to have been 
altered, by the pressure, from a convexity, like the opposite one, 
to a concavity. The septum is deflected toward the exostosis. 

These growths arise from the periosteum and may occasion 
no inconvenience if no pressure is exerted on surrounding 
tissues, but, when they impinge on the posterior portion of the 



DISEASES OF THE NASAL CAVITIES. 261 

inferior turbinal, reflex asthma may result. They are hard, 
immovable, light pink, and bleed easily on pressure with the 
probe (Plate IV). 

Treatment — Osteomata and exostoses should be removed 
when they have attained to such a size as to occasion symptoms 
of their presence. The former may be removed by the snare, 
strong saw-tooth scissors, curette, or forceps ; the latter by the 
saw (Fig. 139). A strong solution of cocaine must be used, 
preferably 20 per cent. The electric trephine and drills are 
convenient for this purpose, and the dental motor also is 
effective. 

Rhinoliths. 

Deposits of the salts of the nasal secretion are infrequently 
found in the nasal chambers and are, in effect, foreign bodies. 
'They are generally found in the anterior part of the cavities, 
and are of irregular shapes and sizes and of gray or dark color. 
The discharges envelop them and obscure their identity until 
washing reveals their nature. Rhinoliths may develop to such 
a size as to obstruct the nasal passages and give rise to a foul 
discharge and epistaxis. The treatment consists in their 
removal. 

Sarcomata of the Nose and Vascular Tumors. 

These are, fortunately, rare occurrences. Sarcoma and 
carcinoma are sometimes developed in this region. Sarcoma 
does not differ in this locality from its characteristics in other 
situations. It is more likely to be found on the septum, but 
may invade the other nasal walls. It gives rise to pain, obstruc- 
tion of respiration, fetid discharge, and possibly difficulty in 
swallowing and impaired hearing when it extends to the naso- 
pharynx. If it invade the nasal vault the cranial cavity may 
become involved, resulting in a fatal termination. 

Sarcomata are of rapid growth and present a dark, rough- 
ened surface in some instances ; in others they are pale. As 
pressure develops laterally, bulging of the nasal walls becomes 
apparent in the contour of the nose and the prominence of the 
eyes. The gravity of the disease is manifested in a general 



262 



DISEASES OF THE EAR, NOSE, AND THROAT. 



constitutional disturbance. The probe causes bleeding and dis- 
covers a soft, fleshy mass. This is a rapidly-fatal disease of less 
than a year's duration. 

Treatment. — Complete extirpation is the only remedy. 
Anodyne and astringent applications after the disinfecting and 
cleansing washes are only palliatives. 



Carcinoma. 

Cancer of the nasal passages differs in no way from the 
same disease elsewhere. An ulcerating surface with a brown, 
serous fluid, pain and haemorrhage, infiltration of the cervical 
glands, and constitutional symptoms characterize this disease. 
The end is death. 

Treatment. — There is no curative treatment. The growth 
may be somewhat retarded and the suffering ameliorated by 
anodyne and astringent applications. Cocaine and aristol are 
the best. 



Plate IV. 



PLATE IV. 

Figure 1. — Male, set. 38 ; hypertrophy of the entire mucous membrane of 
the nasal cavities ; relieved by means of bougies and galvano-cautery. 

Figure 3. — Rhinoscopic view of above (normal size). 

Figure 2. — Male, set. 30 ; syphilitic perforation and exostosis of septum ; 
mercurial treatment and mitigated stick locally. 

Figure 4. — Rhinoscopic view showing exostosis of septum in the above 
(normal size). 

Figure 5. — Female, set. 26 ; appearance of nasal cavity after loss of septum 
and turbinated bones, and enlargement of the orifice of the antrum through syph- 
ilitic necrosis. Mercurials aud iodides ; extraction of necrosed bones with forceps. 
Potassium-permanganate washes. 

Figure 7. — Rhinoscopic view of above with mirror facing obliquely from left 
to right (normal size). 

Figure 6. — Female, set. 17 ; syphilitic perforation of hard and soft palate ; 
mercurials and iodides ; mitigated stick locally. 

Figure 8. — View of palate through the mouth (in state of active inflam- 
mation). 

Figure 9. — Female, set. 19 ; mucous polypi ; removed with snare ; subsequent 
galvanic cauterizations. 

Figure 11. — Anterior view of above (normal size). 

Figure 10. — Female, set. 45 ; large mucous polypi ; removed with snare ; sub- 
sequent galvanic cauterizations. 

Figure 12. — Anterior view of above (normal size). 

Figure 13. — Female, set. 30; large fibrous polypus of laryngeal vault; re- 
moved with galvanic snare. 

Figure 14. — Male, set. 28; central curvature and exostosis of septum ; longi- 
tudinal incision with knife ; oakum plugs ; exostosis removed with saw. 

[Note. — Represented as seen by gaslight. By daylight the red color appears 

much paler.] 



Plate IV 




Sajous,P/nxit. 



Bunk & M c Fetr,dge, Lith Phi/a 



CHAPTER XXIV. 

DISEASES OF THE NASAL CAVITIES, CONCLUDED. 

Tuberculosis of the Nose. 

Fortunately this is a rare affection. It appears in two 
different forms : an ulceration and a neoplasm, or tumor. The 
ulcer appears on the septum near the orifice of the nostril, and 
may extend from this point to other parts of the nose and it 
may even invade the upper lip. It is more likely to be secondary 
to tuberculous affections of other organs than a primary mani- 
festation. The ulcer appears as a yellow or gray surface with a 
round, elevated, uneven border. There is a purulent discharge, 
more or less tinged with blood, and of a disagreeable odor. 
There is no tendency toward cicatrization, and after being once 
healed it has a strong disposition to break out again. Pain is 
not a common symptom. Sooner or later the disease, which is 
now generally conceded to be due to the bacillus tuberculosis, 
invades the larynx and lungs and terminates in death. 

Treatment. — Cleansing, antiseptic solutions, such as are 
noted in Chapter XVIII, must be freely used. Curettement, 
the galvano-cautery, or chromic or lactic acid, — the latter in 50- 
per-cent. strength, — may be resorted to for the removal of the 
caseous, tuberculous material that forms the base of the ulcer. 
In case of a tumor, it should be removed with the snare and the 
attachment cauterized. Astringents and iodoform are useful in 
retarding disintegration and the invasion of adjacent structures. 
If pain is present, morphine or cocaine may afford temporary 
relief. Codliver-oil should be given, and guaiacol in doses of 1 
to 10 minims after each meal. This is best administered in 
glycerin, milk-broths, or wine. Creasote is often useful. 

Syphilis of the Nose. 

The manifestations of syphilis in the nose correspond to 
the three stages of syphilis as met with in other organs. It 

(263) 



264 DISEASES OF THE EAR, NOSE, AND THROAT. 

may be hereditary or acquired. In the former it appears either 
before the third month of childlife or between the third year 
and the beginning of adolescence. In infants the affection 
simulates coryza, but tends strongly toward suppuration. The 
discharge is more acrid and irritating than that of simple rhini- 
tis, and produces a red and raw appearance of the upper lip. 
The borders of the nostrils are cracked and chapped. Nasal 
respiration is embarrassed, and, in consequence of the interfer- 
ence with sucking, the babe is ill nourished and puny. If the 
disease attack the cartilage or bone, an offensive odor is imparted 
to the discharge. 

The later form of hereditary syphilis presents manifesta- 
tions of the tertiary form. It attacks the cartilaginous and 
osseous septum and then the turbinate bodies, and by carious 
and necrotic processes they undergo more or less complete 
destruction. The supports to the end and bridge of the nose 
disappear and the end may drop down toward the upper lip, 
or, if it remain supported by a remnant of the cartilaginous 
septum, the centre of the bridge may cave in and produce the 
pug-nose deformity. 

Diagnosis. — With care one will be able to distinguish the 
obstinate, persistent, pus-producing rhinitis of a syphilitic infant 
from an ordinary cold in the head which in an uninfected child 
tends toward speedy resolution. Mucous patches may be dis- 
cernible in the nares and a papular eruption on the skin. These 
children are often badly nourished, old looking, and unprom- 
ising. After taking into account all the characteristics men- 
tioned, if in the later form there exist any doubt as to the 
nature of the disease, a course of antisyphilitic treatment will 
dispel the uncertainty. 

Prognosis. — If the pathological process has not involved 
the cartilaginous or bony walls, and if the patient is not greatly 
debilitated, the chances of recovery are good. 

Treatment. — Cleanliness and specific medication are often 
rewarded by brilliant results. The antiseptic alkaline sprays 
given in Chapter XVIII are indicated, after which tincture of 
iodine applied to the ulcerating surfaces will be followed by 



DISEASES OF THE NASAL CAVITIES. 265 

healthy granulations and cicatrization. If the ulcers do not 
cicatrize promptly, it is advantageous to dust the parts with 
aristol (Fig. 32) after the cleansing process. I generally use 
the mixed treatment, — small doses of mercury with potassium 
iodide. The latter may have to be given in increasing doses until 
the system is saturated. This treatment, vigorously pursued 
and carefully watched, gives gratifying results. 

In great debility and malnutrition codliver-oil, tonics, and 
improved sanitary surroundings may be necessary. When 
extensive deformity of the nose takes place, it may become 
necessary to resort to a rhinoplastic operation to restore the 
contour and continuity of the organ. \Yhen the cartilaginous 
support of the end of the nose has been destroyed so as to let 
the tip fall upon the upper lip, I have restored the natural lines 




Fig. 143.— The Author's Xasal supporter. 



by a device shown in Fig. 143, which I have named a ,; nasal 
supporter." It is fashioned to fit into the tip of the nose, so 
that the sides or wings of the supporter will correspond to the 
alae nasi. It is so placed as not to be visible when in position. 
I first had them constructed of aluminium, but the bright, 
reflecting surface was observable. Later I experimented with 
vulcanized rubber, and found that, after making the surface a 
dead black, it answered all requirements. The improvement 
in the facial appearance after restoring the pendulous nose to 
its normal position is something to be appreciated. 

Destruction of the major portion of the septum nasi does 
not necessarily result in external deformity. I have under 
observation such cases in which there is no external discover- 
able evidence of the internal architectural desolation. 



266 diseases of the ear, nose, and throat. 

Lupus of the Nose. 

Lupus affecting the nasal cavities is a rare affection except 
as an extension from primary lupus of the face or pharynx. 
The nodules — which are found more abundantly on the septum 
than on the turbinals — break down, ulcerate, and discharge a 
foul-smelling, purulent secretion. In and about the prominent 
border of the ulcer can be seen the hard, but resilient, tumefac- 
tions, or nodules. As the discharges dry upon the ulcers, brown 
or greenish crusts form, offering more or less obstruction to the 
nasal respiration. Pain, radiating to the surrounding structures, 
is complained of, and the ulcer is sensitive to touch. 

Treatment. — In addition to the detergent and antiseptic 
sprays mentioned in treating of ozaena, etc., the treatment is the 
same as that given for lupus of the ear. 

Glanders. 

Glanders is a disease derived from the horse and is encount- 
ered among horse-farriers, coachmen, etc. It is due to a specific 
contagion and manifests its presence by the formation of pustules 
which give way to ulcers of the skin. It attacks the nose and 
throat, from which a bloody pus is discharged in large quan- 
tities. Constitutional symptoms characteristic of a serious sys- 
temic invasion or toxaemia indicate the gravity of the disease. 
When the infection extends to the lymphatic glands and skin 
in various parts of the body it is termed "farcy." 

This disease is either acute or chronic. The acute form is 
ushered in by symptoms similar to those of the eruptive fevers: 
chills, nausea, vomiting, fever, and red rash on the nose and 
face resembling erysipelas. This is followed by the appearance 
of blisters, which burst and leave their contents on the skin to 
dry into crusts. On removing these an ulcerating surface is dis- 
closed that shows no inclination to heal, but rather to extend 
over the surrounding parts. The pustular eruption invades the 
nose and throat, causing embarrassment of respiration. The 
copious, tenacious discharges from the nose and throat, and 
sometimes from the eyes keep the patient occupied to free the 
passages. In the chronic variety the secretion is not so copious, 



m 






DISEASES OF THE NASAL CAVITIES. 267 

and it may be lacking, except in the desiccated form of scabs on 
the nasal and pharyngeal membrane. 

Symptoms suggestive of tuberculosis come on later : col- 
liquative diarrhoea and sweats, huskiness of the voice, and dif- 
ficulty of deglutition and respiration from tumefaction of the 
mucous membrane of the pharynx and about the glottis. 
Great prostration and delirium precede death. 

The acute form is rapidly fatal, lasting only about a week, 
while the chronic variety may persist for several months or a 
year. About half of all the cases die. 

The diagnosis may be obscured by the many symptoms 
that are characteristic of other affections, such as typhoid fever, 
rheumatism, syphilis, pyaemia, etc., but the history of the pa- 
tient, exposure to infection from horses, and lack of further 
pathognomonic symptoms of other diseases must be considered. 
As distinguished from typhoid, we have the pronounced nose, 
throat, and skin eruptions and discharges and ulcerations ; from 
articular rheumatism, pains in the muscles and tenderness 
surrounding the joints ; from syphilis, the constitutional dis- 
turbance and absence of proving by specific remedies ; from 
pyaemia, even when abscesses are found there is little or no 
chilliness. 

Treatment. — No antitoxin has yet been evolved that acts as 
a specific for this disease. From the nature of the case it is to be 
expected that such a remedy will yet be found. No treatment so 
far tried has decided influence in curing or retarding the progress 
of this virulent affection. It must be left to the practitioner to 
meet symptoms and indications as they arise and appeal to his 
knowledge of the general principles of medicine. 

FURUNCULOSIS OF THE NOSE. 

Boils in the nose are a common source of discomfort. 
They occur repeatedly in some individuals and cause soreness, 
redness, and swelling of the end of the nose. Small furuncles 
often develop just within the opening of the nostril, especially 
on the upper border, and originate in a hair-follicle. They 
render blowing and wiping of the nose very painful. 



268 DISEASES OF THE EAR, NOSE, AND THROAT. 

Treatment consists in local and constitutional remedies. 
To the boil situated within the border of the naris a pledget of 
cotton is applied after moistening it with a 20-per-cent. solution 
of camphor-menthol in lavolin, or a 12-per-cent. solution of 
carbolic acid in glycerin may be substituted, as recommended in 
the treatment of furuncle of the ear. When pus is found it is 
evacuated, giving an opportunity for the remedies to enter the 
cavity. This treatment should be followed by the application 
of the yellow-oxide-of-mercury ointment, 5 grains to the ounce 
in vaselin, or the carbolic-acid ointment. Sulphide of calcium 
has a reputation of repressing or preventing pus formation, and 
can be given in those cases in which recurring crops of furuncles 
torment the patient. I have used with satisfactory results 
arsenious acid in doses of -^ grain three times a day, increasing 
gradually to two or three times that quantity for a short time, 
until the patient was free from these symptoms, and, if they re- 
appeared after a few months, repeating the treatment with larger 
doses continued for a longer time. This treatment has been 
successful in breaking up what appeared to be an established 
habit of body in which furuncles broke out with every spring- 
open in g. 

Anosmia. 

Absence or loss of the sense of smell may be due to central 
lesion or peripheral diseases. Affections of the Schneiderian 
membrane may destroy the nerve-termini or offer such obstruc- 
tions as to render them inaccessible to odors. Acute inflam- 
mation of this membrane and suppuration of the adjacent 
cavities (such as the frontal sinuses), that cause the membrane 
to become bathed in purulent discharges, and syphilis and 
atrophic rhinitis, ozeena, etc. (that produce destruction of the 
membrane), cause, on the one hand, temporary impairment or 
absence of the function of the olfactory nerve, and, on the other, 
irreparable loss of smell. 

Blows in the region of the olfactory bulb, and occasionally 
on other parts of the skull, cause injuries to the bulb from which 
it does not recover. Excessive tobacco-smoking, snuff-taking, 
and opium-using either blunt or obliterate the sensibilities of the 



DISEASES OF THE NASAL CAVITIES. 269 

olfactory nerve. The sense of taste generally suffers more or 
less in all these instances. 

Treatment. — Anosmia due to acute inflammation of the 
nasal and connecting cavities generally disappears when the 
cause of it is removed. The appropriate treatment then is the 
same as for the inflammation that produces it. When the loss 
of smell has existed for several years the outlook for its restora- 
tion is not encouraging. Yet I have seen a partial return after 
the whole mucous lining of the nasal cavities had gone through 
a protracted siege of ulceration in consequence of an irregular 
physician spraying the cavities with a corroding fluid by mistake, 
resulting in a complete loss of the sense. To complicate the 
case there was syphilitic infection. In such cases the treatment 
detailed for syphilis of the nose and ozasna is appropriate. Ab- 
solute cleanliness and nerve-tonics, such as strychnia and the 
faradic current, are indicated. The negative electrode is placed 
over the root of the nose and the positive on the occiput, both 
electrodes being saturated with salt water. 

Parosmia. 

In parosmia the sense of olfaction is perverted. This 
happens even where the sense is normal for all objective odors. 
Various subjective odors are complained of, all disagreeable, 
such as oils, carrion, kerosene, etc. A physician under my care 
is annoyed by a constant subjective odor of " greasy rags or soap- 
grease." This symptom may be due to disease of the nasal 
mucous membrane, the decomposition of retained nasal secre- 
tions, disease of the olfactory nerve, or cerebral lesion and over- 
stimulation of the nerve. As an example of the latter : I have 
under treatment a gentleman who for many years has been 
engaged in the perfume business and during that time has grad- 
ually lost his sense of smell without any apparent causative 
lesion in the nasal cavities. Perverted olfactory function has 
been observed in the insane and epileptics. 

Treatment. — If the nasal membrane is diseased and if 
hypertrophies, polypi, etc., are present to account for increased, 
retained, and perverted secretions, suitable treatment, such as 



270 DISEASES OF THE EAR, NOSE, AND THROAT. 

has already been discussed, may remove the disgusting symptom, 
but if the cause lie in the nerve or its origin, or exist in the 
imagination as an hallucination, the indications for treatment 
are not so plain. If the olfactory bulb is the seat of the disease, 
galvanization or faradization as mentioned for anosmia may 
prove beneficial. 

Deformities and Diseases of the Nasal Septum. 

Exostoses and synechias have already been considered and 
are illustrated by Figs. 130 and 131 and Plate IV. It is un- 
usual to find a nose with an interior that is architecturally sym- 
metrical. The septum in many instances is either curved, thick- 
ened, or even doubly curved so as to present a sigmoid flexure 
or a corrugated appearance. If the deformity is not sufficient 
to produce pressure on the turbinate bodies and consequent irri- 
tation, epistaxis, and obstruction to nasal respiration (Plate V) 
no symptoms referable to the anomaly are present. According 
to Zuckerkandl, the septum is not found deviated before the 
seventh year, but I have under observation a boy 5 years and 
9 months of age with deflection, spurs on both sides, hypertro- 
phied turbinals, and adenoids. 

The causes of malformed septa are not known, but the 
theories are many. The deflection may be so exaggerated as to 
give a twisted or bent appearance to the whole nose. The 
irregularity is limited to the anterior and middle sections of the 
septum. 

Symptoms of nasal irritation — epistaxis, discharge, reflex 
neurosis (such as asthma), nasal voice, naso-pharyngeal catarrh, 
etc. — result from considerable septal deformities. The diag- 
nosis is readily made on inspection with brilliant, reflected 
illumination. 

Treatment. — If the deformity is limited to the cartilaginous 
septum the most satisfactory procedure in my experience has 
been the amputation of the offending projection by means of 
the septum-knife (Fig. 138). The method is described in con- 
nection with the figure. I have always taken pains to avoid 
perforating the septum, but I have seen many cases in which 



DISEASES OF THE NASAL CAVITIES. 271 

surgeons had made apertures without any unpleasant con- 
sequences. When the bony partition is involved the saw or 
the drills are called for. Various punches have been con- 
structed to fracture and restore the deviated septum, after which 
splints and tampons are employed to maintain the reduced 
deformity in proper position. 

BLOOD-TUMORS OF THE NASAL SEPTUM. 

Haemorrhage takes place between the mucous membrane 
and the cartilage from blows, etc. Fractures of the septum 
occasionally result in hsematomata. These tumors are easily 
recognized and should be opened before their contents degen- 
erate into a purulent mass, resulting in abscess. (See "Treat- 
ment " under " Abscess.") 

ABSCESS OF THE NASAL SEPTUM. 

Like blood-tumors, abscesses are generally in the cartil- 
aginous portion of the septum. They may assume such pro- 
portions as to completely blockade the nostrils and compel 
mouth-breathing. In a case recently under my care the 
swellings were symmetrical and had attained such a size as 
to protrude sufficiently from the nostrils to be plainly visible. 
They are usually the result of blows, and their history and 
appearance render the diagnosis easy. 

Treatment. — Abscesses of the septum, like blood-tumors, 
should be opened, their contents evacuated, and the cavities 
cleansed with dioxide of hydrogen. Then equal parts of alco- 
hol and tincture of iodine should be injected so as to wash out 
the cavity. The dressing is completed by packing aristol gauze 
between the opposite wall and the septum so as to cause coap- 
tation of the separated mucous membrane to the cartilage again. 
This method may prevent perforation of the cartilage, which is 
a frequent sequel of these diseases. 

PERFORATION OF THE NASAL SEPTUM. 

An aperture is not infrequently found in the cartilaginous 
part of the septum when patients are unaware of its presence 



*27*J DISEASES OF THE EAR, NOSE, AND THROAT. 

(Plate IV), but occasionally a small perforation causes a whis- 
tling sound as the current of air moves rapidly over it, annoying 
the patient and attracting the attention of others. A prominent 
educator of my acquaintance is troubled in this manner. He 
is apparently in excellent health and there is no assignable cause 
for the anomaly. Perforations are usually considered as indica- 
tive of syphilis, but they are not necessarily so. I have often 
been unable to trace them to any specific taint. They may 
occur as the result of impaired nutrition or the habit of picking 
at the nose with the fingers. Abrasions are produced, and the 
crusts that form over them are not allowed to remain until heal- 
ing occurs beneath. In the course of exhausting diseases, such 
as tuberculosis and typhoid pneumonia, the septum may become 
perforated. 

Treatment. — Unless the perforation causes a whistling sound 
perceptible to others or annoying to the patient, no treatment is 
required except the application of vaselin or some stimulating 
ointment to the border of the perforation. Treatment does not 
result in its closure. If disagreeable sounds are produced the 
opening can be changed in shape so that its long axis shall cor- 
respond to the air-current. 

In operations on the nose Delavan (Journal of Laryngology, 
1895) deprecates perforating the vomer on account of the dis- 
proportionate shock resulting. French (New York Medical 
Journal, December 1, 1894) perforates the septum when neces- 
sary for breathing-space, but insists on proper after-treatment, 
and Wright insists on thorough antiseptic treatment before and 
after operations on the nose. 

Fractures of the Nose. 
The bones of the nose are not easily or often broken. The 
arched contour and the cartilaginous portion serve to protect 
against such accidents. A blow or fall upon the nose sideways, 
however, may drive the bones inward and produce deformity, 
or a powerful force, like the kick of a horse, may shatter the 
osseous arch. The deformity produced by such accidents is 
shocking. The sense of smell is likely to be destroyed on 



DISEASES OF THE NASAL CAVITIES. 273 

account of the damage done to the olfactory nerves. Examina- 
tion under ether will reveal the nature and extent of the injury, 
which is readily apparent. The fact that such accidents are 
liable to produce concussion of the brain should not be lost 
sight of in forming a prognosis. 

Treatment. — Pain, bleeding, oedema, swelling, and emphy- 
sema of the tissues demand immediate attention to check the 
haemorrhage, relieve the pain, and reduce the swelling. Ano- 
dynes and the ice-bag (Fig. 78) meet these requirements. Then 
the fractures must be reduced to as perfect coaptation of the 
parts as possible, since nasal deformity, above all others, influ- 
ences the business and social interests of the patient. The solid- 
silver Eustachian catheter can be bent to the proper shape and 
inserted beneath the depressed bones to elevate them to their 
correct level while the fingers of one hand support them from 
without and assist in nicely adjusting them. If restored to 
their normal relations they remain so, since there is no muscular 
contraction to again displace them. Union usually takes place 
rapidly. 

Congenital Deformities of the Nose. 
These are exceedingly infrequent occurrences. If a de- 
formity consist of an impervious membrane of the posterior 
nares it must be perforated to establish nasal respiration. 

Foreign Bodies in the Nose. 
The nose, like the ear, is a favorite receptacle for foreign 
bodies introduced by children and the insane. Beans, peas, 
pebbles, etc., are not infrequently found lodged in these cavities. 
The act of vomiting occasionally forces the ejected matter into 
the post-nasal space. Bodies inserted into the nostrils are gen- 
erally located near the vestibule in the inferior meatus and are 
readily seen on inspection. Sneezing, lacrymation, nasal ob- 
struction and discharges are the symptoms that point toward 
the invader. Berries so absorb the serum and swell that their 
increased calibre and the tumefaction of the mucous membrane 
occlude the offended nostril. Unless the body is removed it 

18 



274 DISEASES OF THE EAR, NOSE, AND THROAT. 

provokes inflammation and ulceration, with frontal and facial 
neuralgia and a purulent discharge more or less discolored with 
blood. The inflammatory process may extend backward to the 
post-nasal space and to the opposite nostril, compelling oral 
respiration and causing loss of smell and impairment of hearing 
from involvement of the Eustachian tube. Decomposition of 
the retained secretions causes a fetid odor and the occasional 
expulsion of cheese-like masses. 

If the obstructing body has been crowded or snuffed back- 
ward into the middle portion of the meatus, it may be shielded 
from view by the swollen turbinal or by a covering of the dis- 
charges. The secretions should be soaked up by the careful 




Fig. 144.— Hartman's Forceps. 



application of absorbent cotton on the carrier. This is better 
than to syringe or spray the nose, for there is less liability of 
forcing the body farther out of reach. After drying the cavity 
a 10-per-cent. solution of cocaine is applied to the tumefied 
turbinal, so as to contract it and afford a view of the whole 
interior of the cavity. The probe will then detect any alien 
substance. 

Treatment. — Foreign bodies should be removed as early 
as possible to prevent serious consequences. This can generally 
be accomplished by the angular forceps (Fig. 144). They 
should be applied with care not to crowd the body farther 
inward. It is best not to close the jaws of the instrument until 



til 



DISEASES OF THE NASAL CAVITIES. 275 

one is certain that it embraces the body a little beyond its centre, 
otherwise it is likely to slip off, and in doing so propel the body 
still farther from view. In the case of a berry of a plant, like 
the bean that has become softened and enlarged by the absorp- 
tion of moisture, a sharp hook like the one found in the author's 
middle-ear case can be made to imbed itself in the substance 
of the body and glide it out of the canal. In some instances 
a blunt hook, the snare, or mouse-tooth forceps offers some 
advantages. 

Maggots in the Nose. 

This is a condition rarely found except in tropical climates. 
The eggs of flies are deposited in or about the nares, maggots 
are hatched, and destruction of the soft tissues and even of the 
nasal bones results. Itching, crawling, gnawing sensations and 
intense pain are experienced. A bloody, purulent discharge of 
fetid character appears. The intense inflammation may invade 
the surrounding structures, causing redness and oedema of the 
face and meningitis, with convulsions, coma, and death. 

Inspection readily reveals the cause of the trouble. 

Treatment. — Chloroform is the most efficient remedy. In- 
halation may be sufficient to destroy the larvae ; if not, it should 
be injected into the nose after enough has been inhaled to pre- 
vent pain. This is made to syringe out all the maggots and 
effectually empty the cavities. After-treatment should be at- 
tended to according to the condition present until the health of 
the membrane is restored. 



CHAPTER XXV. 

DISEASES OF THE ACCESSORY CAVITIES OF THE NOSE. 

Inflammation of the Antrum of Highmore, or 
Maxillary Sinus. 

This disease occurs sometimes as a complication of acute 
rhinitis, and if severe is accompanied by a sense of uneasiness 
or pain and tenderness in the antral, orbital, and frontal regions. 
These symptoms are more likely when there is obstruction to 
the outward flow of the secretions. If the disease does not 
subside coincidently with the subsidence of the rhinitis, a 
chronic suppuration results, or empyema. It may arise as a 
sequel to diseases of the teeth, especially the first and second 
molars, or in connection with the eruptive fevers and 
syphilis. 

This affection is generally unilateral. Examination reveals 
a purulent discharge in the middle meatus and its foul odor is 
noticed by the patient, showing the difference between this and 
ozsena, in which the sense of smell is destroyed. Empyema of 
long standing affects the general health to such a degree that a 
constitutional disturbance is readily apparent. 

Diagnosis. — This is aided by the use of a 10-per-cent. 
solution of cocaine in the nose to contract the turbinals. If a 
rhythmic pulsation is seen in the pus lying in the middle 
meatus, antral suppuration is suggested. The pus should be 
removed and observation made to determine if it re-appear 
from the antral cavity, issuing from below the middle turbinal. 
Pressure over the maxillary sinus or tapping upon a tooth may 
reveal tenderness. If hydrogen dioxide (peroxide) can be in- 
jected into the antrum through the opening beneath the middle 
turbinal, the usual effervescence will disclose the presence of 
pus. Some operators prefer to enter the cavity through the 
(276) 



DISEASES OF THE ACCESSORY CAVITIES OF THE NOSE. 277 

socket of a tooth, which may need to be sacrificed for this 
purpose, while others open the wall of the inferior meatus. 
Still others perforate the thinner wall of the middle meatus, 
Lnder cocaine, going outward and downward to avoid the orbit, 
'hen, the author's aspirator (Fig. 63) may succeed in sucking 
the pus from the cavity. The patient is instructed to make a 
continuous effort, as in pronouncing the consonant part of &, so 
as to elevate the palate and close the post-nasal space. Then 
the air-pump is manipulated, to prove the presence of pus. 

Prognosis. — This is not an inspiring one. The nature of 
the case is unfavorable for spontaneous resolution, and if the 
bone is necrotic a tedious time is to be expected. 

Treatment. — As a complication of acute rhinitis, the treat- 
ment for the latter is indicated. If the mouth of the sinus is 
closed it should be cleansed with the antiseptic sprays mentioned 
in Chapter XVIII, with dioxide of hydrogen, and then moistened 
with a cocaine solution to contract the tissues and open the 
hiatus. If there is much pus in the antrum or if it is inspis- 
sated, it is not an easy matter to evacuate and cleanse the sinus 
through the ostium maxillare. The opening is so small that it 
may be necessary to penetrate the bone. Some operators, like 
the late Dr. Gunn, make a crucial incision in the cheek, and 
perforate through the canine fossa, but it is better to penetrate 
through the alveolus of a tooth, especially as a molar may prove 
to be the exciting cause of the trouble. 

The weight of argument and experience is in favor of 
entering the sinus through the nose, just below the natural 
opening. A curved drill or cannula and trochar are best 
adapted for this purpose, for the cannula can be left in position 
until the cavity is thoroughly cleansed and medicated. The 
after-treatment should be conducted similarly to the medicinal 
treatment detailed for middle-ear suppuration. 

Miscellaneous. — Phlegmonous inflammation of the antrum 
is a very rapidly fatal form of inflammation. 

Tumors of the antrum are exceedingly rare, but require 
extirpation through the anterior wall. Daly {New York Med- 
icalJournal, November 10, 1894) urges early operation in antral 



278 DISEASES OF THE EAR, NOSE, AND THROAT. 

disease to prevent the transformation of a benign growth into a 
malignant one. 



Ethmoid Diseases. 

An inflammation of the nasal membrane sometimes extends 
into the ethmoid cells, the membrane of which, like that of the 
mastoid cells, lines the osseous cavities and serves as a perios- 
teum. Hence an inflammation of this membrane is readily 
communicated to the bony walls themselves, resulting in caries 
and necrosis. Pain is referred to the root of the nose and 
the orbital and temporal regions. The disease may extend so 
as to produce a bulging prominence between the eye and the 
root of the nose, and the eyeball may protrude abnormally. In 
a girl of 17 years, now under treatment (Fig. 148), the arch of 
the nasal bones was widened, the vault of the nares was filled 
with mucous polypi, and the flow of the muco-purulent dis- 
charge was enormous, necessitating the carrying about of a 
bundle of cloths instead of a handkerchief. There were also 
adenoids in the vault of the pharynx, hypertrophied tonsils, and 
chronic suppuration of both middle ears. The polypi, adenoids, 
and tonsils were removed, but the polypi were reproduced with 
mushroom-like rapidity. The ethmoid cells were opened up and 
curetted, and she is improving satisfactorily, the discharges from 
the ethmoid cells and ears having ceased. 

Diagnosis. — The antrum is often involved coincidently, 
and it is sometimes difficult to make a differential diagnosis 
between the two. However, the pain in ethmoiditis is referred 
to the root of the nose and back of the eye, and the eye symp- 
toms serve to clear up the uncertainty. The discharge is gen- 
erally seen where it occurs in antral suppuration, but the smell, 
in this disease, is more likely to be impaired or lost. 

Prognosis. — When ethmoiditis is a simple concomitant of 
acute rhinitis it subsides together with the principal disease. 
Suppuration is a serious condition, for it may invade the orbit 
or extend to the cerebral meninges. 

Treatment. — Antiseptic, detergent washes already given 
in the first chapter of Part II — dioxide of hydrogen, etc. — 






DISEASES OF THE ACCESSORY CAVITIES OF THE NOSE. 279 

must be employed for cleansing purposes. All polypi should 
be removed and then the curettes shown in Fig. 84 can be used 
to scrape out carious and necrotic tissue. If the middle turbinate 
body is too large to admit of proper observation and manip- 
ulation, it must be removed as already described. The anterior 
ethmoid cells are in communication with this turbinal; hence 
the advantage of its excision. After-treatment is the same as 
for antral suppuration. 

Polypi sometimes take their origin from the ethmoid cells, 
producing pressure on the surrounding structures. The result 
is apparent, especially in the increased breadth of the nose and 
the prominence of the eye. Osteomata produce like appear- 
ances. The treatment for growths in this locality consists in 
extirpation. 

Sphenoid Disease. 

It may be observed that I have departed from the custom 
of adding " al " to the adjectives ethmoid and sphenoid. This 
is because it is etymologically correct to do so ; it is in keeping 
with the American tendency to brevity and terseness, and in 
conformity to the common use of the corresponding term " mas- 
toid " instead of "mastoidal." These terms are Greek adjec- 
tives merely transferred into English, and are not rendered more 
perfect by additional terminations. 

Sphenoiditis occurs as a complication or sequel of inflam- 
mation of the nasal and accessory cavities and of meningitis. 
The symptoms are not pathognomonic and this affection is 
difficult to differentiate from disease of the ethmoid cells. The 
pain is deeply seated, the discharge empties into the throat, and 
dimness of vision, strabismus, and prominence of the eyeball are 
symptoms characteristic of this disease. 

The prognosis is unfavorable on account of the tendency 
to invade the cranial cavity. 

Treatment. — The methods already described for diseases of 
the accessory cavities are applicable here. If it should become 
necessary to open and curette the sphenoid sinus, the instrument 
should be passed over the middle turbinal, backward and up- 
ward until it enters the lower part of the cavity. The sinus 



280 DISEASES OF THE EAR, NOSE, AND THROAT. 






can be opened through its under wall, also by perforating 
through the pharyngeal vault immediately back of the posterior 
nares. Subsequent treatment has been indicated in treating of 
the other sinuses. 

Tumors are rare in the sphenoid sinuses, but if they pro- 
duce blindness or other serious symptoms they must be removed. 

Diseases of the Frontal Sinuses. 

Inflammation of these cavities occurs from extension of 
rhinitis. It is not to be expected under the twentieth year, since 
these sinuses, being developed from the anterior ethmoid cells, 
are not formed earlier. Acute inflammation is characterized by 
a severe, continuous, frontal headache and pain about the eyes. 
There is tenderness over the sinuses on percussion and on press- 
ure beneath the supra-orbital ridge. Nausea and vomiting are 
occasionally present. The pain may not be due entirely to the 
swelling of the mucous membrane lining the cavities, but to 
loss of the natural air-pressure, for I have observed that the 
propelling of air impregnated with a nebula of camphor-menthol 
into the sinuses gave decided relief. 

When the infundibulum, or passage between the nasal 
and frontal cavities (Fig. 146), becomes clogged, the retained 
secretions, mucus or pus, will cause great pain. The press- 
ure may be sufficient to cause absorption of the osseous 
partition separating these sinuses, or bulging may take place 
downward and outward so as to encroach and press upon the 
eyeball. 

Suppuration of the frontal sinuses is an infrequent disease. 
The pus can be seen in the middle meatus under good illumi- 
nation, flowing downward from the region of the sinus-opening. 
It should be wiped away and the area watched to see the source 
of the discharge. If the pus break through the posterior wall 
of the sinus, there are symptoms of brain compression, drowsi- 
ness, headache, stupefaction, etc. This complication induces 
purulent meningitis. 

The symptoms point quite distinctly to the seat of the 
trouble, and are not so obscure as in sphenoiditis. The electric 



DISEASES OF THE ACCESSORY CAVITIES OF THE NOSE. 281 

lamp and condenser of Heryng are useful in making diagnoses 
in this class of diseases. Transillumination of the frontal 
sinus is accomplished by applying it to the lower border of 
the supra-orbital ridge and inner angle of the orbit while 
the room is made dark. In health the sinus is illuminated 
up to the superciliary ridge, but in case of the presence of pus 
it is dark. 

Treatment — The first indication is to subdue the pain. 
If the inflammation occur in the course of acute rhinitis the 
treatment for that is appropriate and effective here. An appli- 
cation of a 10-per-cent. solution of cocaine to the sinus-opening 
may so contract the swollen tissues as to open the duct, give 
exit to the pent-up secretions, and relieve the pain. The deter- 
gent, antiseptic sprays given in Chapter XVIII are useful in 
this affection. After cleansing the cavities by sprays and 
having the patient repeatedly blow his nose, great relief is 
afforded by throwing a nebula or vapor of a 10-per-cent. solu- 
tion of camphor-menthol in lavolin into the nostrils with the 
air-current directed toward the naso-frontal duct. This tends 
to evacuate any retained secretions and to restore the normal 
air-pressure in the sinuses, besides medicating the remote mem- 
brane as ordinary treatment fails to accomplish. 

In the acute stage the ice-bag (Fig. 78) is indicated to 
subdue and avert the inflammation. It should be applied over 
the frontal protuberances and the root of the nose. If this 
should not afford relief, or if it prove irritating, hot fomentations 
may be substituted. Any obstructing hypertrophies or tumors 
must be removed as previously described. If the discharge 
contained in the sinuses cannot be liberated by opening the 
naso-frontal duct with air-pressure, cocaine, or a probe, it may 
be necessary to penetrate the sinus directly, near the internal 
angle of the orbit, at which point the cortex is quite thin. 

This procedure is similar to that which has already been 
detailed for opening the mastoid antrum and removing the dis- 
eased contents. Tumors of the frontal sinuses are treated on 
the principles already laid down for tumors of the other acces- 
sory cavities. 



282 



DISEASES OF THE EAR, NOSE, AND THROAT. 



Eye Affections in Relation to Diseases of the Nose.* 






The eye is directly connected with the nasal cavities by the 
nasal duct (Fig. 145), which is lined throughout with mucous 
membrane the same as that lining the nasal cavities, covering 
the globe of the eye and lining the lids. The lacrymal artery 
— through its branch, the anterior ethmoid — supplies both 
the lacrymal sac and the nasal duct, and the nerve-supply is 







Fig. 145.— Dissection Showing Nasal Duct and its Relations. 

1, inferior turbinate bone; 2, nasal duct and valves; 3, middle turbinate body; 
A, lacrymal sac ; 5, lacrymal canaliculi and their orifices. 

received in common from branches of the ophthalmic nerve and 
Gasserian ganglion. We have, therefore, a direct route through 
the nasal duct for the passage of morbific germs from the nose 
to the eye ; and the nose, under certain pathological conditions, 
becomes a nidus for aggravating causes of ocular symptoms. 

*By Allen T. Haight, M.D., Assistant Surgeon to the Illinois Charitable Eye and 
Ear Infirmary ; Lecturer on the Ear, Nose, and Throat in the Illinois Medical College ; 
Assistant in Ophthalmology at the Chicago Polyclinic. 



DISEASES OF THE ACCESSORY CAVITIES OF THE NOSE. 283 

The common blood-supply, with anastomoses and veins from the 
duct and sac, and the direct relation of accompanying nerves 
show that certain mechanical or pathological conditions existing 
in one may produce pronounced symptoms in the other. For 
instance, irritation of the Schneiderian mucous membrane may 
produce lacrymation, and we may have more or less severe 
ocular symptoms accompanying common coryza, measles, etc. 

The principal ocular symptoms which in certain cases 
depend on pathological conditions existing in the nose are lac- 
rymation, photophobia, conjunctival injection, pericorneal injec- 
tion ; smarting, burning, and swelling of the lids ; phlyctenular 
troubles, epiphora, purulent ophthalmia, etc. 

H. Gradle (Archives of Ophthalmology, New York, 1887), 
in systematizing the ocular symptoms dependent on pathological 
conditions of the nose, finds the following classes : — 

" 1. Lacrymation without primary lesion of the tear-pass- 
ages of the eye and due to some chronic abnormality of the 
nasal passages. 

" 2. Fullness of the lids and itching, possibly with lacry- 
mation and more or less pain and with asthenopia especially 
marked in one eye. Patients with these symptoms aggravated 
have also a refraction, or muscular, anomaly. 

" 3. Periodic discomfort (itching of the lids), allied to hay 
fever or co-existing with conjunctival lesions, at first of the 
follicular enlargement and finally of a formation of large, flat, 
yellowish, follicular granules which disappear in the winter. 

" 4. Photophobia with or without pain in the eyes, these 
being often blood-shot, with little nasal annoyance, but decided 
itching. 

" 5. Injection of the pericorneal vessels, together with 
varying degrees of the above symptoms, chronic and persistent. 

" 6. Acute congestion of the lids with irritable nose, ery- 
sipelatoid in character, subject to recurrence, lasting from two 
to six days. 

" 7. Sudden oedema of the lids without congestion, the 
attack lasting a few hours." 

In the present treatise we shall not draw such precise 



284 DISEASES OF THE EAR, NOSE, AND THROAT. 

symptomatological lines, but shall confine our consideration of 
the subject to two classes, — viz. : (1) pathological conditions of 
the eye dependent on hypertrophies, deformities, or mechanical 
abnormalities of the nose; (2) pathological conditions of the 
eye resulting from the passage of morbific material from the 
nose through the nasal duct or intermediate tissue of the eye. 
One of the frequent causes of ocular troubles is chronic hyper- 
trophic rhinitis, especially that form in which the mucous mem- 
brane is subjected to repeated, sudden engorgement of the 
blood-vessels from very slight irritation. In these cases we 
usually have a copious, watery discharge and severe inflamma- 
tion of the inferior turbinated body, especially marked in the 
anterior half, associated sometimes with mucous polypi in the 
middle meatus. The eye symptoms occurring with this con- 
dition are lacrymation ; photophobia ; burning and smarting 
of the lids, with deep injection, especially marked at the 
margin ; and not infrequently ciliary and conjunctival injection. 
Polypi of the mucous type so situated as to form a wedge 
between the septum and the inferior turbinal, or situated so as 
to fill the superior meatus, give rise to persistent ocular lesion. 
Deflected septum, spurs, large ridges on the septum, and 
synechia? play an important part in the production of sympa- 
thetic ocular conditions. Bishop cites a case of amblyopia of 
the left eye, greatly impaired hearing, tinnitus aurium, and a 
sensation of fullness in the left ear cured by the removal of an 
osseous synechia between the left middle turbinated bone and 
the nasal septum. 

Polypi in the superior nasal cavities sometimes produce 
that peculiar facial deformity known as "frog-face," where the 
nose becomes widened between the eyes and the eyes protrude. 
Pressure on the upper part of the nasal duct produces epiphora 
and catarrhal conjunctivitis, which can be effectually cured only 
by the removal of the obstruction and the restoration of the 
nose to its normal function. 

Abnormal development of the ethmoid and sphenoid 
markedly affects the function of the ocular muscles or the 
acuteness of vision. Overdevelopment of the ethmoid, espec- 



DISEASES OF THE ACCESSORY CAVITIES OF THE NOSE. 285 

ially in the anterior part, will sometimes produce entire stenosis 
of the upper part of the nasal duct, and we have epiphora from 
pressure. Following this we get blennorrhcea of the lacrymal 
sac and possibly dacryocystitis. Abnormal development of the 
posterior portion of the ethmoid may produce widening of the in- 
terorbital space ; displacement of the origin of the internal recti 
muscles, with high degrees of astigmatism ; and occasionally 
divergent strabismus following. 

Overdevelopment of the sphenoid may, by pressure upon 
the optic nerve, produce permanent atrophy, limitation of the 
field of vision, and partial or complete color-blindness. 

Hypertrophies, polypi, or tumors in the superior nasal 
sinus may produce temporary blindness or high degrees of 
amblyopia, which are ameliorated -or cured by the removal of 
the obstruction. 

Pathological Conditions of the Eye Resulting from the Pass- 
age of Morbific Material from the Nose through the Nasal Duct 
or Intermediate Tissue to the Eye. — The ready means of access 
of infectious germs of all kinds to the eye from the nose by 
means of the nasal duct (Fig. 146) renders the eye liable to 
attack in nasal diseases, such as ozaena, hydrorrhcea, hyper- 
trophic rhinitis with watery discharge, gonorrhoea, syphilis, 
diphtheria, etc. The conjunctiva is a very delicate and sensitive 
membrane, far more so than the Schneiderian mucous membrane, 
and easily yields to the attack of morbific germs. These germs 
sometimes gain entrance to the eye by direct migration, but are 
very frequently forced into the eye by blowing the nose, sneezing, 
and not infrequently by the use of the Politzer air-bag. The 
cul-de-sac of the inferior turbinated body (Fig. 146, 4) is the 
receptacle for the collection of material which is, or becomes, 
decomposed, and finds its way or is forced into the lacrymal 
sac and to the conjunctiva, and we have a blennorrhcea, conjunc- 
tivitis, phlyctenular keratitis, or ulcer of the cornea following, 
which will not yield to treatment until the origin of the trouble, 
the nasal affection, has been corrected. In the fall and spring 
of the year, particularly, the attention of the ophthalmic surgeon 
is attracted by the number of children who present themselves 



'266 



DISEASES OF THE EAR, NOSE, AND THROAT. 



with corneal ulcers or phlyctenular troubles, usually attended 
by nasal affections. There is great congestion of the turbinals, 
profuse watery discharge, and the formation of crusts on the 
nostrils, the sores extending down on the upper lip. The eye 
symptoms are persistent, are attended by lacrymation and by 




Fig. 146. 

1, middle turbinated body turned aside and beld by a hook ; 2, nasal duct and valves ; 
3, canal leading to the maxillary and frontal sinuses ; U, inferior turbinated body showing 
location of the mouth of the nasal duct in the cul-de-sac. 



increasing photophobia and resist local treatment until the nasal 
affection is cured. The treatment of nasal affections is fully 
given in other chapters of this work. 

The most common ocular affection caused by diseased con- 
ditions of the nose is disease of the lacrymal apparatus. We 
have many cases of lacrymal trouble which are in no way 
influenced by conditions in the nose, but are caused by the 
passage of germs from the eye through the canaliculi to the 
lacrymal sac or into the nasal duct. We may have stenosis of 



DISEASES OF THE ACCESSORY CAVITIES OF THE NOSE. 287 

the canaliculi situated in any place between the puncta and the 
opening into the lacrymal sac. In this class of cases we have 
epiphora as an early symptom, with sometimes a contraction or 
atrophy of the lacrymal sac, but more frequently dilatation 
and blennorrhcea. When the stenosis is situated in the nasal 
duct below the sac (Fig. 145, 2) we have abnormal dilatation of 
the sac and accumulation of muco-purulent secretion. In both 
cases the permanent symptom is epiphora, and we may have, 
following this, conjunctivitis, and dacryocystitis. 

One-half of the above cases have their origin in nasal 
affections. Hypertrophic rhinitis may cause stenosis of the 
lower part of the nasal duct, the inflammation extending 
through the canal to the sac. Atrophic rhinitis with fetid dis- 
charge is most frequently the cause of lacrymal trouble ; the 
morbific germs pass through the canal to the sac and remain 
there the nidus of infection until the disease is established. 
Empyema of the antrum of Highmore may be the cause of 
lacrymal disease, as the contents of the antrum may enter the 
nasal duct directly or purulent secretion from the antrum may 
pass from the nose through the nasal duct to the sac. 

Treatment of Lacrymal Diseases. — The first point to be 
settled, if possible, is the cause of the existing condition. If 
the disease is traceable directly to pathological conditions exist- 
ing in the nose, then the nose should receive proper treatment 
in conjunction with the treatment of the lacrymal apparatus. 

If the epiphora is due to stenosis in the canaliculi, occlu- 
sion of the puncta, blepharitis, eversion of the puncta, etc., 
these conditions must be remedied. When the lacrymal sac is 
filled with acrid or muco-purulent discharge, this should be 
evacuated by means of firm pressure by the thumb or finger on 
the sac, pressing the retained secretion out through the puncta 
(Fig. 145). The eye should then be thoroughly cleansed with 
a saturated solution of boric acid, after which the sac should be 
washed out. In order to introduce a lacrymal syringe it is 
necessary to enlarge the calibre of the puncta. To do this I 
introduce the canaliculous knife into the canaliculus (Fig. 147), 
the cutting-edge being turned toward the eye, and by retracting 



288 



DISEASES OF THE EAR, NOSE, AND THROAT. 



the lid with the thumb and drawing the knife out, make a small 
incision in the punctum perpendicularly to the palpebral fissure 
large enough to insert the end of the syringe or a small probe. 

This operation maintains the integrity of the canaliculus, 
and the pressure of the lids on the wound tends to keep the 
edges apart and prevent adhesion. 

For washing the sac I have derived great benefit from the 



following solution : — 

B Fl. ext. hyclrastis, 

Zinci sulpli., . 
Aquae destil., . 



q. s. 



ad 



^iss. 
gr. iv. 
5U— M. 




Fig. 147.— Tear-gland and Drainage. 

1, 3, orbital and palpebral portions of lacrynial gland ; 2, fibrous band dividing the 
gland ; U, 5, orifices and branches of the lacrymal canal ; 6, lacrymal sac. 



which I inject with the lacrymal syringe every other day, 
using the solution as hot as the patient can well stand. 

If a stricture of the canal exist below the sac I insert, if 
possible, a No. 5 or No. 6 Bowman probe, and follow this with 
an injection of the above solution. If this or other conserva- 
tive treatment fail, the stricture must be treated surgically, 
which course is given in detail in works on the eye. 

Gould quotes Hamilton in detail in the following cases : — 
Case I. — Empyema of the antrum and unilateral hyper- 
trophic rhinitis of the left side, attended with the following eye 



DISEASES OF THE ACCESSORY CAVITIES OF THE NOSE. 289 

symptoms: (1) concentric contraction of the visual fields for all 
colors, (2) accommodative asthenopia, (3) retinal hyperesthesia, 
and (4) photophobia with blepharospasm and intra-orbital neu- 
ralgia. The evacuation of the empyema and its cure were 
speedily followed by the disappearance of the eye symptoms. 

Case II. — Ecchondrosis of the triangular cartilage and 
chronic rhinitis. This case was attended with the following eye 
symptoms: (1) asthenopia, (2) pain in the eyeball, (3) injection 
of the eyes when used for close work, (4) blepharospasm, and 
(5) contraction of the visual fields. These symptoms disap- 
peared on removal of the growth. 

Case III — Spine of the bony septum causing chorea. The 
following eye symptoms were present: (1) asthenopia, (2) sub- 
jective color-sensations, (3) sneezing, and (4) contraction of the 
field of vision. These symptoms disappeared on removal of the 
spine of the septum. 

Case IV. — Advanced chronic atrophic rhinitis, with middle 
turbinate hyperplasia. The following eye symptoms were 
present: (1) asthenopia, (2) lacrymation, (3) pufhness of the 
lids, and (4) contraction of the visual field. These symptoms 
were relieved by the treatment of the nasal condition. 

Case'V. — Syphilitic ozaena. The following eye symptoms 
were present (Transactions of the Intercollegiate Medical Con- 
gress of Australasia, 1889, vol. ii, p. 779): (1) asthenopia, (2) 
lacrymation, (3) pericorneal injection on using eyes, and (4) 
contraction of the visual fields, which was temporarily removed 
by the use of amyl-nitrite. These eye symptoms were amelio- 
rated as the nose improved. 

Case VI. — Polypi, nasal and naso-pharyngeal, with eye 
symptoms similar to those recorded. 



19 



CHAPTER XXVI. 
DISEASES OF THE NASO-PHARYNX. 

Nasopharyngeal Catarrh. 

Synonyms. — Post-nasal catarrh ; rhino-pharyngitis ; retro- 
nasal catarrh; follicular naso-pharyngeal catarrh. 

Pathology. — Naso-pharyngeal inflammation may be acute 
or chronic, but the acute stage rapidly merges into the chronic 
form, leaving a thickening of the mucous membrane, — a pro- 
liferation of tissue that gives rise to a roughened and granular 
appearance of the membrane and increased secretion from the 
mucous glands. 

Etiology. — Sudden and extreme changes in meteorological 
conditions, especially in a low, damp climate are undoubtedly 
the chief exciting causes of this disease. Inhaled dust is an- 
other important etiological factor ; but climatic conditions are 
of prime importance; otherwise, those who live in a dusty 
atmosphere, but in a warm, high, dry, equable climate, would 
suffer equally with those under the reverse conditions. 

This disease is most common in the region of the Great 
Lakes and, indeed, in many other parts of America. Even in 
Colorado, the Mecca of consumptives, this disease prevails. But 
the soil favors this, for it is so light and sandy that the rains 
percolate through into the subsoil in a few hours, leaving on the 
surface a fine coat of dry dust, the toy of the winds and the 
torment of catarrh. I have never experienced elsewhere such 
dust-clouds as I have seen in Denver. In the Mississippi Valley 
and the Great Lakes Kegion the barometrical and thermomet- 
rical changes are rapid and excessive. The thermometer often 
falls thirty degrees or more in a few hours, and half that much 
in as many minutes. In hot summer-days, with southerly winds, 
cold waves sweep down from the northwest, catching the people 
in thin clothing, chilling the skin, and causing internal con- 
gestions that naturally attack the respiratory passages. The 
(290) 



DISEASES OF THE NASOPHARYNX. 291 

dampness of the atmosphere and the prevalence of dust aid in 
locating the seat of irritation in the most exposed air-cavities. 
After these sudden attacks of cold waves an influx of patients 
usually attests the cold-giving nature of the changes. I have 
found San Francisco no better than Chicago in climatic con- 
ditions. The fogs of the early morning and the bitterly-cold, 
penetrating winds of the afternoon, with only a few hours of 
congenial warmth to lure one to don warm- weather attire, pre- 
sent the conditions favorable to the production of nasopharyn- 
geal catarrh. But the reverse of this picture is to be found by 
a twenty-minute ride across the bay to Oakland. There one 
may doff his overcoat and bask in the balmy sunshine of summer, 
while his neighbors a few miles distant shiver in the ocean- 
winds. But even here we cannot escape the irritating dust that 
plays hide-and-seek with the cilia of the nose. For catarrhal 
patients the climate of Los Angeles or San Diego is preferable 
to that of San Francisco ; but even in these delightful gardens of 
America there is no escape from dust. 

The part played by this irritant in the causation of post- 
nasal catarrh is easily understood when we consider the con- 
formation, position, and lining of the naso-pharyngeal cavity. 
Its shape is such as to receive and change the course of the 
current of air as it strikes the vault and posterior wall of the 
pharynx, and all the dust-laden air inhaled through the nose 
must come in contact with this part. The foreign particles not 
removed by previously impinging on the nasal cilia or mem- 
brane find lodgment here, and, if sufficient moisture has not 
been absorbed by contact with the nasal chambers proper, the 
secretions of the retropharyngeal space are taxed to perform 
this function. The resulting storage of dust and the drying of 
the membrane, which is devoid of the acute sensibility charac- 
teristic of the nose and larynx, and therefore of prompt reflex 
efforts at dislodgment, tend to excite irritation and consequent 
inflammation. Other predisposing causes of naso-pharyngeal 
catarrh are discussed in the first chapter on general considera- 
tions of ear, nose, and throat diseases. 

This disease is undoubtedly more prevalent in America 



292 DISEASES OF THE EAR, NOSE, AND THROAT. 






than in European countries. The reasons assigned for its prev- 
alence in various parts of this country are sufficient to account 
for this difference. It is not a contagious affection, like epidemic 
influenza, neither can it be termed hereditary, but its universal 
presence is certainly suggestive of a predisposing hereditary 
influence. It is not limited to the frail, but is just as likely to 
be encountered in the robust. 

Symptomatology. — In the early history of naso-pharyngeal 
catarrh the patient notices a sense of irritation in the upper and 
back part of the throat. This provokes attempts at clearing 
the throat, or hawking, which is irksome to the patient and 
disagreeable to his companions. A sense of constriction and a 
tired or aching feeling is often present, especially while speaking 
in public. The vocal organs weary easily, and the necessary 
efforts to clear the throat during a lecture or sermon are weari- 
some to both speaker and audience. Clergymen are frequent 
subjects of this complaint. There is almost a universal habit 
among them of efforts to relieve this irritable condition of the 
upper throat. 

Posterior rhinoscopy discloses a thick, tenacious, light- 
yellow secretion sticking to the posterior wall of the pharynx. 
On removing this discharge the membrane appears very red and 
roughened by the formation of granulations. These are round 
and punctated or irregular and flat, with broad bases suggestive 
of particles of a filled sponge. Frequently they coalesce, es- 
pecially at the sides of the throat just behind and below the 
posterior faucial pillars, and form a welt extending upward and 
outward in the direction of the Eustachian orifices. These 
point to the throat deafness so often met with in catarrhal 
climates. The blood-vessels are often engorged and tortuous 
and stand out prominently above the surface of the surrounding 
tissues. The Eustachian prominences are swollen and reddened 
and the orifices constricted or closed. Extension of the inflam- 
mation a little farther through the Eustachian openings results 
in tubal catarrh and impaired hearing, as already described in 
the ear division. The pharyngeal, or Luschka's, tonsil is some- 
times hypertrophied, and in children adenoid vegetations may 



DISEASES OF THE XASO-PHARYNX. 293 

so occlude the vault of the pharynx as to preclude nasal respi- 
ration (Plates II and III). Mouth-breathing and its train of 
evil consequences result. The faucial pillars are more or less 
involved, presenting a swollen, infiltrated condition. 

Diagnosis. — There is little likelihood of confounding this 
affection with any other. Adenoid vegetations are confined to 
the young and are easily seen with the rhinoscopic mirror and 
felt by the finger. The same may be said concerning polypi. 
Syphilis causes sore throat, but the characteristic erosions and 
the history, added to the testimony of antisyphilitic remedies, 
serve to dispel any doubt. 

Prognosis. — Although it is the practice of charlatans to 
represent this disease as being dangerous to life and leading to 
pulmonary consumption, its early history does not confirm such 
statements. In its early stages it yields readily to proper treat- 
ment, but after it has existed for a number of years it becomes 
persistently chronic and intractable to all methods of treatment. 
However, much relief can be afforded by hygienic measures and 
proper cleansing and stimulating topical applications. 

Treatment. — The first object of treatment is perfect clean- 
liness ; detergents — such as Dobell's and Seller's solutions — 
should be used in the form of sprays, both through the anterior 
nares and throat, to dislodge all secretions and crusts that adhere 
to the naso-pharyngeal walls. If these alkaline, antiseptic 
sprays, that dissolve the tenacious secretions and dislodge them 
in ordinary cases, are not sufficient to remove them in this form 
of catarrh, cotton, twisted upon the curved post-nasal carrier, 
should be used to wipe out all the discharges. Then stimulating 
and tonic sprays should be applied with the Davidson or De 
Vilbiss atomizers. Camphor-menthol in lavolin, 5-per-cent. 
coarse spray, or a 10-per-cent. solution in the form of a nebula, 
in the hand-dilator, will afford decided relief. A tonic, antiseptic 
spray is had in eucalyptus in lavolin, 4 per cent. ; or, as a tonic 
nebula to be used in the hand-dilator, an excellent preparation 
consists of oil of cubebs, 25 parts; pure camphor-menthol, 10 
parts; and lavolin, 65 parts. However, the latter solution 
must not be used in the form of a coarse spray. This and a 



29-1 DISEASES OF THE EAR, NOSE, AND THROAT. 






10-per-cent. solution of camphor-menthol inhaled through the 
throat and exhaled through the nose act as decided stimulants 
and tonics. It is my practice to prescribe for home treatment a 
3-per-cent. solution of camphor-menthol in lavolin, to be used 
every morning and night. The patient is instructed to throw a 
sufficient spray of this preparation into both nostrils and throat 
to satisfy him that the parts are entirely covered with the medi- 
cine. The application of this remedy proves very grateful and 
refreshing to patients, especially to public speakers. Upon being 
used at bed-time it remains in contact with the mucous mem- 
brane during the hours of repose, when no efforts are made to 
clear the nose ; so that its action is continuous over a number 
of consecutive hours. 

Excessive tobacco-smoking must be interdicted, and those 
who continue to smoke must be instructed that the habit of 
forcing smoke outward through the nose acts as an irritant and 
aggravates the existing condition. The inhalation of dust; 
irritating gases, like those from matches, etc. ; exposure to cold 
and damp and drafts of cold air, especially upon the back of the 
neck and back of the arms ; and exposure of the feet to cold 
and wet must be avoided. Animal fibre must be always worn 
next the skin. Woolen is preferable to silk. Cotton and linen 
must not be used for underclothing. Consisting, as they do, of 
vegetable fibre, they favor rapid evaporation of the perspiration 
(causing chilling of the skin), and contraction of the capillary 
vessels and resulting internal congestion. The diet must be 
plain and nutritious, avoiding an excessive use of meats, sweets, 
and alcoholic stimulants. 

Atrophic Catarrh of the Naso-pharynx. 
This disease usually accompanies the same condition of the 
nose which has already been described, but it may exist inde- 
pendently of atrophic nasal catarrh. In the early stage of this 
affection the mucous membrane of the naso-pharyngeal space 
usually appears dry and shining. Later, crusts are formed 
similar to those described in ozsena. Sometimes quite large 
patches of those crusts, which adhere closely to the membrane 



DISEASES OF THE NASOPHARYNX. 295 

and are removed with difficulty, are expelled. They are gen- 
erally of a dirty-white or greenish color and sometimes brown 
or even black. The latter color is usually found where patients 
are exposed to the inhalation of a smoky atmosphere in the 
neighborhood of factories and hotels and buildings in which 
soft coal is largely used in furnaces. These crusts sometimes 
are detached with such great difficulty that the patient is under 
the necessity of inserting his finger into the vault of the pharynx 
and detaching them with the finger-nail. 

The pathology of this disease is the same as for nasal 
ozsena, to which the reader is referred. 

The symptoms consist of a sensation of dryness in the 
throat, which is much more disagreeable than the presence of an 
hypersecretion. When crusts form, decomposition takes place, 
imparting a foul odor to the breath. The efforts of the patient 
at dislodgment of these secretions cause gagging and some- 
times vomiting, and for this reason they produce gastric dis- 
turbances. 

The points of diagnosis are identical with those given for 
ozaena, under the heading of " Atrophic Nasal Catarrh." 

The prognosis is unfavorable. This is a persistent, chronic 
disease, which is not easily amenable to treatment. However, 
much relief may be afforded until such time as the processes of 
nutrition can be so improved as to give permanent relief. 

Treatment. — Antiseptic, alkaline, detergent solutions — such 
as DobelFs and Seller's — must be used abundantly to dissolve 
and dislodge the crusts. . When no crusts are present, but 
merely a pale, dry, shining, mucous membrane, remedies that 
stimulate the muciparous follicles to secretion must be used. 
These consist of the eucalyptol, iodine, and cubeb sprays already 
mentioned. Further treatment for this affection is the same as 
that laid down for nasal ozsena. 

Fibrous Polypi of the Naso-pharynx. 
Fibrous polypi in this locality are of infrequent occurrence 
(Plate IV). They are not found above the twenty-fifth year 
and occur more frequently in men than in women. They cause 



296 DISEASES OF THE EAR, NOSE, AND THROAT. 

obstruction to nasal respiration, dyspnoea, epistaxis, and facial 
disfigurement. 

Pathology. — These tumors occur singly and are attached 
by a broad pedicle to the roof of the pharynx. They are 
dense, smooth, and of a dark-red color. The blood-vessels of 
the interior are smaller than those of the mucous membrane 
covering them. Bleeding takes place easily ; so that palpation 
with the probe causes a sanious discharge. These polypi may 
develop to such an extent as to invade the throat even to a level 
with the epiglottis. 

Etiology. — Their cause remains in obscurity. 

Symptomatology. — The most prominent symptoms are 
difficult breathing in consequence of the nasal obstruction, nose- 
bleeding, stupidity, a nasal intonation of the voice, and difficulty 
in articulation of speech. Pressure upon the orifices of the 
Eustachian tubes may cause obstruction to the ventilation of 
the middle ears, Eustachian salpingitis, and consequent deafness. 
When these growths assume large proportions they produce 
sufficient pressure upon the surrounding structures to broaden 
the base of the nose and increase the width between the eyes, 
giving the appearance suggestive of the " frog- face." Pressure 
may be sufficient to cause separation of the nasal bones and 
absorption of the facial and cranial bones, producing intra- 
cranial complications. There is generally a copious muco- 
purulent discharge and difficult deglutition. 

Diagnosis. — These tumors are differentiated from mucous 
polypi by their hardness, frequent .bleeding, and their occur- 
rence only under the twenty-fifth year. They are distinguished 
from adenoid vegetations in the vault of the pharynx by the soft, 
spongy, lobulated appearance of the latter and their occurrence 
only in the very young. The appearance of the two in the 
rhinoscopic mirror and the sensations imparted to the finger 
introduced into the naso-pharyngeal space render a differential 
diagnosis not difficult. 

Prognosis. — Fibrous polypi pursue a steady growth until, 
in from three to five years, they prove fatal. If their develop- 
ment can be repressed by local treatment until the patient 



DISEASES OF THE NASOPHARYNX. 297 

arrives at the age of 25 years, the prospects of recovery are 
fair. 

Treatment. — These growths should be removed with the 
galvano-cautery snare, electrolysis, ecraseur, powerful cutting 
forceps, or a curette. Before the operation for removal is com- 
menced the body of the polypus should be secured by a strong 
thread so as to prevent its dropping into the throat and pro- 
ducing suffocation. After removal, the attachment of the 
polypus should be thoroughly cauterized. 

Fibromucous Polypi of the Naso-pharynx. 
These tumors are of somewhat rare occurrence. They 
vary in size from one to three inches (two to eight centimetres). 
They are smooth, oval, and of a dusky-red color and occasion 
nasal obstruction and deafness, but no haemorrhage. One 
serious inconvenience occasioned by them is the inability to 
blow the nose. 

Pathology. — Unlike the fibrous growth, which occurs on 
the under surface of the basilar process, the fibromucous polypi, 
springing from the connective-tissue fibres and mucous elements, 
naturally partake of their character. They are dissimilar to 
the fibrous polypi ; adenoid in appearance, texture, and history ; 
and do not tend to recur after extirpation. 

Treatment. — Evulsion should be made with strong forceps 
through tthe mouth, or the cold- wire or galvano-cautery snare 
can be used thl cough the nose. After their removal the site of 
attachment should be cauterized. 

Malignant Tumors of the Nasopharynx. 
These tumors are of very rare occurrence. Thej^are at- 
tended with pain in the throat and back part of the nose, 
extending to the ear ; catarrhal symptoms, with increased dis- 
charges from the nose and throat; difficulty in swallowing; and r 
as they progress, general impaired nutrition. They are likely 
to be of the sarcomatous type, either pear-shaped or lobulated. 
Their growth is rapid, and there is a strong tendency to recur- 
rence after their removal. Only a microscopic examination will 



298 DISEASES OF THE EAR, NOSE, AND THROAT. 

reveal their true nature. They are likely to be mistaken for 
fibrous polypi, but are less dense, softer to the touch, and 
present quite a different history. 

The prognosis is hopeless. 

Treatment consists in their removal, if possible, with the 
means already detailed for operations upon fibrous polypi. 
Supportive and tonic remedies should constitute a part of the 
treatment. 

Adenoid Vegetations in the Vault of the Pharynx. 

Synonyms. — Adenomata ; hypertrophy of the pharyngeal, 
or Luschka's, tonsil. 

Pathology. — These growths occur in two varieties. The 
first consists of spongy, stalactite projections from the vault of 
the pharynx ; the second of smooth, fibrous tumors of irregular 
shape. They are very vascular and contain lymph-cells and a 
follicular structure resembling that of the oral tonsils. 

Etiology. — This is mostly a disease of childhood and is 
oftenest seen under the tenth year. Heredity is an important 
factor. Sometimes several children in the same family are sub- 
ject to these growths. They are always to be looked for in 
children with hypertrophic rhinitis and enlarged faucial tonsils. 
Symptomatology. — The most striking features in a pro- 
nounced type of this affection are the parted lips, prominent 
eyeballs, obliteration of the normal lines of expressk/n of the 
face, and a consequent appearance of listlessj^fess and inferiority 
(Fig. 148). Mouth-breathing, a ^oii'sy respiration, snoring, and 
a lack of resonance of <" V e voice are the typical symptoms. There 
is a characte;'jf f Cic"thickness of speech, or nasal intonation. As 
Che ::; ce f "said, "He intunes in his nose." Such children are 
absent-minded and have the appearance of being inattentive, 
which may be due either to mental dullness or impaired hearing. 
There is a plentiful, tenacious discharge of a grayish or bloody 
color. Examination with the finger causes bleeding. There is 
a history of recurring colds in the head, earache, diminished 
hearing, noises in the ears, or otorrhcea. There may be press- 
ure on the Eustachian tube or an extension of the adenoid 






I 



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LECTURES 

ON 

Auto-Intoxication in Disease, 

OR 

SELF-POISONING OF THE INDIVIDUAL. 
By CH. BOUCHARD, 

Professor of Pathology and Therapeutics, Member of the Academy of 
Medicine, and Physician to the hospitals, Paris. 

Translated, euitn a Preface, 
By THOMAS OLIVER, M.A., M.D., F.R.C.P., 

Professor of Physiology, University of Durham ; Physici»r- to the 

Royal Infirmary, Newcastle-upon-Tyne ; and Examiner in 

Physiology, Conjoint Board of England. 



The Thirty-two Lectures in this volume deal with 
the toxins, pathogenic processes generally, elimina- 
tion of poisons, preliminaries to the study of the 
toxicity of emunctory products, intestinal antisepsis, 
and of various diseases due to bacillary products. 
No subject commands a greater interest; none de- 
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OVER. 




Fig. H8.— Mouth-breather (17 years old). 

Adenoid vegetations in the vault of the pharynx; hypertrophied oral tonsils; 
bilateral nasal polypi ; spreading of nasal bones, producing great breadth of nasal arch ; 
protrusion and wide separation of eyeballs (frog-face) ; suppurative ethmoiditis requir- 
ing curettement ; and chronic suppuration of both middle ears. 



DISEASES OF THE NASO-PHARYNX. 299 

inflammation through the tube to the ear. The growths are 
light pink, turning to red on being irritated. They obstruct 
posterior rhinoscopy, and are often unequally developed on the 
two sides. The symptoms given are of typical cases ; in many 
they are not so well defined. 

Diagnosis. — The symptoms described render this a simple 
matter. The rhinoscope is not easily used in children, and I 
rely mostly on the digital examination. 

Prognosis. — The tendency is to absorption during early 
adolescence. 

Treatment. — While it is the practice of some rhinologists to 
treat adenoids with washes, sprays, caustics, the galvano-cautery, 
etc., for periods varying from four to fourteen months, I much 




Fig. 149.— F. U. Greene's Mouth-gag. 



prefer the one painless operation, lasting but five minutes and 
insuring a radical cure. The best anaesthetic for this operation 
is ethyl-bromide. Before administering it the little patient 
should be calmed into a tranquil state of mind, for if there is 
great excitement the drug is not so efficacious. The instru- 
ments are sterilized by boiling or steaming, and the mouth-gag 
(Fig. 149) is inserted between the molar teeth. It must be care- 
fully held in place by an assistant until the operation is com- 
pleted ; otherwise it slips out of place and allows the jaws to 
close, after which they are with difficulty separated. The pa- 
tient is held in a sitting posture on an assistant's lap (Fig. 150). 
An ounce tube of bromide of ethyl is emptied into the air-tight 
inhaler and administered as in etherization, allowing no air to 
enter. Anaesthesia is induced in about one minute and lasts 



300 



DISEASES OF THE EAR, NOSE, AND THROAT. 



about five minutes. Not more than half an ounce is taken, but 
the remainder will not keep for subsequent use. The patient 
quickly recovers consciousness, and after lying down for a few 
minutes he is ready to be taken home. 




Fig. 15U.— Position of Child for Adenoid Operation or Intubation ; 
Mouth-gag Introduced. 

The instant anaesthesia is complete Gottstein's large or 
small ring-curette (Fig. 151) is inserted behind the velum and 
upward near the vomer to engage the central, highest mass first. 
Then the cutting-surface is passed backward and downward in 
contact with the posterior pharyngeal wall as far as the growths 




Fig. 151.— Gottstein's Ring-curette. 



extend. The same movement is executed on either side 
wherever there are growths, sweeping them all out by three or 
four passes of the curette. Finally the finger is inserted to 
discover if any remain. If so, they may be detached with the 
finger-nail or the curette. 



DISEASES OF THE NASOPHARYNX. 301 

As soon as all the adenoid tissue is extirpated, the gag is 
removed and the patient's body is inclined forward, with the 
face downward. The surgeon loudly commands the patient to 
" spit it out! " Hence the blood escapes through the nose and 
mouth and the patient at once begins efforts at expulsion, and 
the blood is thereby prevented from entering the larynx or the 
stomach. 

If the faucial tonsils are hypertrophied, they are removed 
before the adenoids. This order of operating presents two 
advantages : the space through which we operate is amplified 
and there is no bleeding from above to obscure the tonsillotomy. 
The operator must waste no time, but, if he act promptly and 
rapidly, there is sufficient time for all this procedure. 

Haemorrhage lasts but a few minutes and generally ceases 
by the time full consciousness is restored. This method deprives 
the operation of the horrors experienced by children whose 
adenoids are extirpated without anaesthesia ; and neither chil- 
dren nor parents, who are excluded from the room until the 
bleeding ceases, retain any revolting memories of the affair or 
of their doctor. Many cases receive no after-treatment ; but it 
is better to give a spray of camphor-menthol and lavolin — 3 
per cent. — with an atomizer (Fig. 118) for home use three times 
a day for a w T eek or more. 

While instances of severe haemorrhage from this operation 
are reported, I have never witnessed any. In my experience 
with quite a considerable number, none but satisfactory results 
have obtained. One needs to take care not to wound the 
orifices of the Eustachian tubes or to drag a mass of the 
adenoid tissue down into the throat and leave it hanging there 
by the pharyngeal membrane intact. I have observed this con- 
dition after what must have been a hasty and incomplete oper- 
ation. The finger should not be inserted into the pharyngeal 
vault while the curette is in action ; but one should not fail to 
examine immediately after curetting to ascertain if the adven- 
titious tissue has been completely removed. I have never ob- 
served any bad effects from ethyl-bromide. It is as safe as ether 
and far preferable for such short operations. 



302 DISEASES OF THE EAR, NOSE, AND THROAT. 

The operation itself is not difficult, and I have never re- 
garded it as dangerous. It is a simple curettement in an easily 
accessible cavity, providing the mouth is kept properly gagged. 
In ahout seven hundred operations by my assistants and myself 
with bromide-of-ethyl anaesthesia no accident or haemorrhage of 
importance has occurred. 



PART III 



Diseases of the Pharynx. 



Plate V. 



PLATE V. 

Figure 1. — Male, aet. 21 ; anterior view of extensive osteo-enchondroma of septum, 
occluding completely left nasal cavity ; mass reduced with dental engine. 

Figure 2. — Lateral view of above. 

Figure 3. — Male, set. 24 ; posterior view of asymmetrical nasal cavities of above case ; 
complete stenosis of the left naris. 



Figure 4. — Male, set. 44 ; anterior view of deviation of septum to right, causing 
partial occlusion of cavity. 

Figure 5. — Lateral view of above, showing concavity of septum anteriorly and a 
convexity posteriorly, due to abnormal thickness of the septum. 

Figure 6. — Posterior view of above, showing the thickened septum pressing on left 
middle and inferior turbinated bodies ; causing asthma. Thickness reduced with surgical 
engine, passing burr under the mucous membrane ; asthma relieved. 



Figure 7. — Male, aet. 48 ; relaxation of soft palate, causing symptoms of elongated 
uvula ; astringents found useless ; amputation of uvula. 

Figure 8. — Female, set. 22; elongation of uvula, causing cough, expectoration, etc., 
and general symptoms of phthisis ; amputation ; complete relief. 

Figure 9. — Female, get. 27 ; position of mouth in forcible separation of jaws during 
tonsillitis; further examination impossible; diagnosis established by character of paiu, 
color of tongue, odor of breath, and dysphagia. 

Figure 10. — Male, aet. 28 ; hypertrophy of the tonsils ; amputation with tonsillotomy 

Figure 11. — Appearance of tonsils in above case during an attack of tonsillitis. 

[Note. — Represented as seen by gaslight. By daylight the red color appears much paler.] 



V. 







/.- I th Ph 9 



CHAPTER XXVII. 
DISEASES OF THE PHARYNX. 

Acute Pharyngitis, or Simple Sore Throat. 

Pathology. — Acute sore throat may be characterized by a 
simple hyperemia or an active inflammation with round-cell 
infiltration of the mucous membrane of the pharynx and serous 
effusion in the submucous tissues. The secretions contain 
epithelial cells", pus-corpuscles, and micrococci. 

Etiology. — There is quite a wide divergence of opinion 
respecting the causes of acute catarrhal inflammation of the 
throat. There are excellent students who deny the classic 
theories of taking, or catching, cold. Thorner and Fick com- 
bat the idea. But what shall we say of the common expe- 
riences of life among laymen and doctors alike] When 
individuals possessed of unusual intelligence and powers of 
observation note that certain phenomena invariably follow 
given causes, that exposure of certain skin-surfaces, like the 
back of the neck, to cold draughts of air, is regularly and 
repeatedly followed closely by symptoms of irritation or inflam- 
mation of the nasal or pharyngeal mucous membrane, not a 
few times only, but scores and hundreds of times in a long- 
experience, shall we say that human testimony is not to be 
accepted, that the powers of observation are at fault, the reason 
clouded, and experience a delusion ] Shall testimony of such 
a positive nature as would receive credence, and upon which a 
just verdict would be rendered in law, be not accredited equal 
weight in medicine'? The logic of consecutive circumstances 
and events is no less forceful here than in other departments of 
physics. In the case of certain individuals the exposure of the 
back of the neck for a short time to cold winds is just as 
certain to be followed by an hyperemia or an actual inflam- 
mation of the nasal or pharyngeal mucous membrane as the 
inhalation of the fumes of a lighted match by a person subject 

20 (305) 



306 DISEASES OF THE EAR, NOSE, AND THROAT. 

to attacks of hay fever will precipitate a paroxysm of that dis- 
ease. Chilling of the skin of the chest by exposure to cold 
winds causes a reflex paresis of the blood-vessels of the bronchi 
or lungs, resulting in hypersemia and congestion, or inflamma- 
tion, of the lining mucous membrane. The same condition of 
the corresponding membrane of the nose or throat is caused in 
certain sensitive or predisposed persons by the chilling of the 
feet or back of the head or neck, but not by the impression of 
cold on the nose or throat directly. These causes and effects 
follow each other in such quick and logical succession, and are 
the subjects of such universal observation and experience, that 
one cannot ignore or resist their force. The theory that these 
diseases are the result of bacterial infection may be, in some 
part, true, for these micro-organisms may easily enough act as 
exciting causes which cannot be resisted by a membrane already 
weakened by paresis of its vessels caused by the impression of 
cold ; but cold is by no means held to be the only predisposing 
or exciting cause of acute catarrhal attacks. Streptococci and 
other germs have been found in the secretions in abundance, 
but their precise relations to the disease, cause or product, have 
not been determined. 

This affection is an accompaniment or a sequel of the ex- 
anthemata, improper use of the voice, traumatic or chemical 
injuries of the throat, iodism, etc. Predisposing causes are 
heredity, impairment of the digestive and eliminative functions, 
living in overheated and ill- ventilated rooms, etc. 

Symptomatology. — The first intimation given of an attack 
of acute pharyngitis is a sense of discomfort in the region of the 
throat and more or less stiffness of the muscles concerned in 
deglutition, or actual pain. The temperature rises in severe 
attacks, especially in children, several degrees, even as high as 
103° or 105° F. In mild attacks there is no fever. The naso- 
pharynx is frequently involved and the symptoms are propor- 
tionately extended. There are likely to be headache and symp- 
toms referable to the ear, such as a feeling of stuffiness, dullness 
of hearing, and ringing in the ears. Of course, these symp- 
toms are attributable to an extension of the inflammation to the 



DISEASES OF THE PHARYNX. 307 

Eustachian orifices or tubes. It is not uncommon to see the 
middle ear involved to the extent of acute otitis and suppuration, 
with perforation of the membrana tympani. The act of swal- 
lowing causes pain, to avoid which the head and neck are made 
to perform certain movements characteristic of painful deglu- 
tition. The voice sounds muffled and obstructed and its use is 
avoided on account of the discomfort produced. During the 
act of swallowing the food is prone to enter the post-nasal space 
and occasion much discomfort. 

After the dry stage of inflammation has passed the throat 
becomes bathed in a sticky mucus. This happens about the 
second day, and soon after this pus-corpuscles begin to make 
their appearance. The efforts to clear the throat of these 
rapidly-accumulating discharges cause so much acute suffering 
that they are often swallowed, when nausea and vomiting are 
likely to follow. The breath becomes very foul and the tongue 
thickly coated, indented, and flabby in severe attacks. 

Early inspection shows a bright-red color of the membrane 
covering the fauces and pharynx (Plate VI). At first this is 
simply hyperaemic, but as exudation of serum takes place there 
appears a swollen, cedeinatous condition, especially marked in 
the loose tissue of the palate and uvula. The velum is thickened 
and its movements restricted and painful. The uvula is swollen 
to much more than its normal size and feels like a foreign body 
in the throat, exciting frequent attempts to swallow. 

The duration of this disease varies from two or three days 
to a week or longer. The high temperature of the initial stage 
drops in a day or two and remains nearly normal. It generally 
develops on examination that the patient has been subject to 
similar attacks with a suggestiveness of periodicity. They are 
expected in the fall-, winter-, or spring- time, which points to 
the probability that there has been a predisposing chronic 
inflammation that requires treatment to avert future attacks. 

Diagnosis. — Simple sore throat cannot always be dis- 
tinguished from the sore throats of measles and scarlet fever 
until the eruption appears or from tonsillitis until the glands 
swell. In rheumatic sore throat there is not likely to be so 



308 DISEASES OF THE EAR, NOSE, AND THROAT. 

marked an cedematous condition of the tissues, but more pain, 
referable to the cervical muscles. 

Prognosis. — The disease lasts only about a week and is 
not dangerous unless it extends to the larynx. 

Treatment. — If seen during the first stage of the attack it 
can be either averted or greatly ameliorated by the adminis- 
tration of atropia combined with morphia in the proportion of 
3-J--JJ- grain atropia to -J grain of morphia. Even in the second 
stage of inflammation, when serum and mucus are pouring 
forth in abundance, the drying effect of these remedies lessens 
the secretion and the consequent painful efforts to swallow it, 
while their anodyne properties reduce the suffering to a min- 
imum. The atropia antagonizes the nauseating, depressing, 
and constipating effects of the morphia. I have often averted 
these attacks in patients who had been in the habit of passing 
through sieges of this disease with such distressing regularity 
that their experience was not to be ignored. Instead of suffer- 
ing for a week or more, the symptoms would either disappeai 
quietly in a few hours or cover a period of only a day or two, 
and with but little inconvenience. 

The use of quinine, which is so common among the laity 
as well as among physicians, leads to serious results in numerous 
instances. I have known families to buy quinine by the ounce 
and keep it in the closet ready for daily doses for the slightest 
ills. Some of the most hopeless cases of deafness I have ever 
met are those occasioned by the use of quinine. It is less 
effective and more harmful than other remedies. At the onset 
of an attack the patient had better go to bed, if the symptoms 
are severe, and take the tablets mentioned containing the atropia 
and morphia, or the coryza tablets made for me by Truax, 
Greene & Company, containing, each, caffeine, -} grain; morphia, 
y 1 ^ grain ; and atropia, g^ grain. There is seldom any neces- 
sity for repeating these more than four or six times during the 
first two days, when the symptoms will often have disappeared. 
It frequently happens that one or two doses are sufficient. The 
effects of one dose last about four or six hours, when the patient 
is directed to take another, providing the symptoms begin 



i to 



DISEASES OF THE PHARYNX. 309 

revive. He is never allowed to know the nature or the name of 
this remedy for sufficient beneficent reasons already set forth 
herein. 

The bowels should be opened with a saline draught or a 
laxative pill. 

The old-fashioned sweats were quite effective, but after 
leaving the bed the skin is like a sensitive plant and every 
breath of cool air has a chilling effect ; so that patients are left 
more liable to take cold after the sweat. Moreover, the excessive 
flow of perspiration is weakening. The air of the room 
should be kept moist during the dry stage of the first day 
or two, and steam-inhalations are grateful. These are best 
produced by utilizing some vessel having a nozzle, that may be 
found at hand in every house, like the tea-pots, into which a 
pint of very hot water is poured. Tincture of benzoin, 
camphor, 10 drops of pure camphor-menthol, or a few crystals 
of menthol are added to the steaming water, a napkin is 
wrapped about the nozzle to protect the lips which are to 
embrace the tip, and this medicated steam is inhaled into the 
throat. It must not be too strongly impregnated with the 
medicaments so as to produce an irritating effect. When both 
nose and throat are suffering from an attack of acute inflam- 
mation, I have found that menthol afforded relief, especially 
during the dry stage, by employing it as follows: A few of the 
crystals are placed in a teaspoon or saucer and held over a 
lamp or stove until the crystals melt and produce fumes that 
penetrate every part of the room. Just enough is used to 
medicate the atmosphere to the point of comfortable inhalation. 
The patient closes or covers his eyes to prevent any smarting 
of the conjunctivae, and is instructed to inhale through both his 
nose and mouth, if nasal respiration is possible. This causes 
a free flow of mucous secretion, that bathes and moistens the 
inflamed membrane and greatly relieves the sense of burning 
heat and dryness. 

In order to obtain a continuous effect of ammonium chlo- 
ride on the blood-vessels, and the soothing effect of Tolu and 
licorice, I have prescribed with satisfaction a tablet consisting of 






310 DISEASES OF THE EAR, NOSE, AND THROAT. 

R Ammonii chloric! i, gr. ij. 

Tincturse opii camphoratie, 
Syrupi scillse compositi, 

Syrupi Tolutani, aa TTLv. 

Extracti giycyrrkizse, gr. iiss. — M. 

This tablet is dissolved slowly in the mouth, and the re- 
sulting medicated saliva is kept in contact as much as possible 
with the inflamed membrane. During the dry stage pilocarpine 
can be used, if it is desired to produce diaphoresis, ^ or % grain 
two or three times during the day, or enough to produce con- 
siderable perspiration. Gargles are not very efficient, since they 
reach only the anterior surface of the fauces and generally pro- 
duce much discomfort. Potassium chlorate has been a very 
popular remedy for a long time, but I have never been able to 
observe any beneficial effect from it, except that of a detergent 
in the form of a wash. The bromide of potash produces more 
of a sensation of relief than the chlorate in solution, and if 
swallowed in 10- or 20-grain doses produces a sedative effect. 

The glycerite of tannin causes an exudation of serum and 
relieves the distended blood-vessels, besides contracting the 
vessels and thus modifying the intensity of the inflammation by 
a double effect ; but the objection to its use is the necessarily 
disagreeable method of applying it to the throat with a camel's 
hair pencil or cotton-applicator. It cannot be sprayed w 7 ith an 
atomizer without heating it to an uncomfortable temperature. 
After using it in my private and dispensary practice for many 
years I must say that it is an effective remedy if thoroughly and 
gently applied, notwithstanding the recently expressed disap- 
proval of this remedy by so eminent an authority as Lennox 
Browne. By applying it several times a day I have seen the 
inflammation subdued and the attack materially shortened. I 
have used guaiacol in these cases, but have found different pur- 
chases to vary considerably in strength. Some samples cause 
but little burning and smarting when applied pure, while others 
are very violent in their action and need to be diluted one-half. 
Patients feel relieved after the applications, particularly in case 
of high temperature. In some instances in which I used the 
pure guaiacol the membrane looked immediately after the appli- 



DISEASES OF THE PHARYNX. 311 

cation as if an escharotic had been used. It was covered with 
a light-gray pellicle, and on the following morning I have found 
the mucous membrane of this area broken down and ulcerated. 
There is the same objection to this that can be urged against 
any remedy that must be applied with a swab or probang. 

Cocaine for this disease is justly condemned by Ingals. As 
he observes, the effect is transitory, unless one takes into account 
the possible after-effects of a contracted drug habit. Thorner 
has experienced excellent results from salol in 10- or 15-grain 
doses four to six times a day. It relieves the pain in both 
pharyngitis and tonsillitis. The application of ice to the throat 
externally, which can be accomplished with the ice-bag (Fig. 
78) and by sucking pieces of ice, if they can be relied upon as 
being free from disease germs, may modify and abbreviate the 
inflammation. Antipyrin, phenacetin, and aconite are useful 
during the fever and painful stage. After a muco-purulent dis- 
charge has formed, the antiseptic alkaline sprays, followed by 
the soothing, oleaginous inhalents of salol, etc., are beneficial in 
cleansing, disinfecting, and protecting the inflamed surfaces. 

The diet must consist of very nourishing fluids, like the 
animal broths, beef-tea, barley- and rice- water, milk, etc. The 
body should be clothed according to the principles laid down in 
treating of acute rhinitis. One should always dress as warmly 
as comports with comfort. 

The strong tendency of this disease to extend to the Eusta- 
chian tubes and middle ears makes prompt and efficient treat- 
ment imperative. The most effective measures for preventing 
or managing these complications are dealt with in the divisions 
on Eustachian tubal catarrh and acute inflammation of the 
middle ear. 

Simple Chronic Pharyngitis. 

Synonyms. — Chronic sore throat; chronic catarrh of the 
throat. 

Pathology. — The condition here is essentially a repetition 
of the process that eventuates in simple chronic rhinitis. Fre- 
quently-recurring attacks of congestion and inflammation cause 



312 DISEASES OF THE EAR, NOSE, AND THROAT. 

a loss of tonus of the blood-vessels, which remain permanently 
dilated. Varicose veins stand out prominently in their tortuous 
courses, and the membrane remains thickened. The infiltrated 
tissues (Plate VI) are deprived of the opportunity of returning 
to their normal condition through the process of absorption 
because of the interruption to this process occasioned by 
repeated attacks. 

Etiology. — Generally, simple chronic pharyngitis is the 
sequel of acute attacks, but it may result from the abusive 
use of alcoholic beverages, excessive smoking, indigestion, and 
torpidity of the liver. Persons exposed to a smoky, dusty 
atmosphere or irritating gases are especially liable to this form 
of catarrh. A diseased condition of the nasal membrane 
predisposes to this affection. 

Symptomatology. — A sensation of stiffness or a parched 
feeling is experienced in the throat, which is only temporarily 
relieved by drinking. The voice is often lowered in pitch and 
becomes easily fatigued. Viscid masses of mucus are some- 
times seen clinging to the posterior pharyngeal wall, and efforts 
to remove them result in explosive, scraping expulsions of the 
air that add to the existing trouble and set up irritation of the 
uvula and velum palati. These parts are thus forced into 
participation in the throat trouble and often are of a deep-red 
color, swollen, and the uvula is elongated. The resulting con- 
tact of the uvula with the tongue aggravates the condition 
already present by provoking a cough and frequent swallowing 
occasioned by a feeling as if a foreign body were in the throat. 

Diagnosis. — The conditions already described render the 
diagnosis a simple matter. It is not likely to be confounded 
with any other disease. 

Prognosis. — This affection is annoying, but not danger- 
ous to life, and the prospect of relief is good if the patient is 
willing to submit to continuous treatment for a considerable 
time. 

Treatment. — After complete cleansing of the pharynx . by 
the alkaline solutions given in Chapter XVIII Sajous prefers 
silver-nitrate solution, 40 grains to the ounce. It reduces the 



DISEASES OF THE PHARYNX. 313 

calibre of the blood-vessels and promotes absorption. If silver 
is used, the strong is preferable to the weak solution. This 
is applied daily with cotton on a holder, with care not to let 
it drip or press out into the larynx. I have found patients 
to experience great relief by using at home — every morning 
and night at first, and later, when improvement is marked, 
only at bed-time — a 3-per-cent. solution of camphor-menthol in 
lavolin. I have prescribed this for hundreds of patients, and 
they often say, many months afterward, that their improve- 
ment was so great and gratifying that they have had the pre- 
scription repeatedly filled, and have obtained the remedy for 
their friends. This is used with a small hand-atomizer (Fig. 
118). 

For office-treatment, after the cleansing throat douche in 
coarse spray witli sufficient air-pressure to dislodge and expel 
all the secretions that may stick to the membrane, I use, for 
a protective and emollient, benzoinated lavolin ; for antiseptic 
and stimulant purposes eucalyptus in lavolin, 4 per cent., and 
pine-needle oil of the same proportions; and, if the membrane 
become too dry from insufficient secretion of mucus, a 25-per- 
cent, solution of oil of cubebs in lavolin. This acts as a decided 
tonic. 

Pernicious habits must be stopped, and indigestion and 
torpidity of the liver overcome by proper treatment and hygiene 
on general principles. 

Acute Rheumatic Pharyngitis. 

Synonyms. — Rheumatic sore throat; rheumatic angina. 

Pathology. — The pathology of this affection is the same as 
in rheumatism, the discussion of which belongs to the province 
of general medical works. The uric-acid diathesis is discussed 
under the heading of "Hay Fever" (page 222). 

Etiology. — In persons who are subject to attacks of sore 
throat the acquirement of the rheumatic habit of body is likely 
to be followed by this type of throat affection. Attacks usually 
follow exposure to cold and damp. 

Symptomatology. — Attacks come on suddenly after the 



314 DISEASES OF THE EAR, NOSE, AND THROAT. 

impression of cold, and announce their presence by pain in 
the throat and great difficulty in swallowing. The pain of 
deglutition is so acute that the patient refrains from eating or 
even quenching his thirst. All this time there appears to be 
an increased secretion and flow of saliva, which necessitates 
frequent spitting or the alternative of swallowing. This act 
keeps the sufferer constantly harassed, for the movements of 
the muscles of deglutition cause exquisite distress, and with 
each act the head and neck are seen to execute certain move- 
ments characteristic of attempts to avert the inevitable painful- 
ness of the act. While the attack lasts the suffering is greater 
than is usually experienced in simple acute pharyngitis, for the 
soreness in the rheumatic form is not confined to the mucous 
membrane of the pharynx alone, but exists in the muscles 
concerned in the movements of swallowing and even in the 
superficial muscles of the neck, such as the sterno-cleido-mastoid. 

These attacks may not last more than a day or two, when 
other parts, like the muscles of the back or the shoulders, may 
be attacked. On the other hand, there are patients who are 
not conscious of ever having had an attack of rheumatism, at 
least, an acute attack, but who are subject to periodical visita- 
tions of the typical throat affection at certain seasons of the 
year, either at the change from winter to spring or in the late fall. 

The mucous membrane of the palate and pharyngeal wall 
appears of an intense-red color and has a puffy, swollen look. 
There is sometimes headache, accompanied with fever of a mild 
grade. After a few attacks those who are subject to them 
readily recognize their character. 

Diagnosis. — The distinguishing features are the suddenness 
and severity of the attack, the exquisitely-painful deglutition, 
the soreness of the cervical muscles, the brevity and shifting 
character of the disease, and the rheumatic history. 

Prognosis. — This disease is self-limited, so far as its mani- 
festations in the throat are concerned, for it passes off in about 
four days, but to return again on exposure. Prompt treatment 
will avert attacks. 

Treatment. — Salicylic acid in some form is the most effective 



DISEASES OF THE PHARYNX. 315 

remedy. I prefer a freshly-prepared salicylate of sodium, and 
generally prescribe it in the following formula : — 

R Acidi salicylici oiij. 

Sodii bicarbonatis, 5ij. 

Elixiris gaultheria?, §ss. 

Glycerini, 3iij- 

Aquae, q. s. ad §iv. 

Misce. Signa : One teaspoonful, in water, every two or four hours. 

This is given every two hours, at first, until a perceptible 
improvement is shown or until the physiological effects are 
manifested : ringing in the ears and slight impairment of hear- 
ing. Then the doses are stopped or diminished or placed 
sufficiently far apart to avoid these effects. The latter are simi- 
lar to those of quinine, and must be avoided as far as possible, 
so as not to produce hyperemia or congestion of the middle 
ears or irritation of the auditory nerves. If the salicylate is not 
well borne, if gastric disturbance and head symptoms indicate 
unusual susceptibility to this drug, salicin can be advantageously 
substituted for it. This is best given in pilular form in doses of 
5 grains, as detailed for the administration of the salicylate. In 
my opinion these preparations are preferable to the alkalies, 
guaiacum, or salol. 

For the fever and pain an ti pyrin affords the most decided 
relief. Indeed, this remedy appears to exercise a special influ- 
ence in quelling this disease, and is superior to phenacetin, 
acetanilid, etc., not only in reducing temperature, but in trans- 
scending the limited action of an antipyretic. Potassium 
bromide, bromidia, or morphia, combined with a proportionate 
amount of atropia, may be called for to subdue the pain. 

As an external application, I have found the following 
liniment efficacious : — 

R Olei tiglii, 5ij. 

Chloroformi, 3ij. 

Aquas ammonii fortioris, 5J. 

Olei sesanii !|iij. 

Misce Signa : Apply on cotton. 

This is used by saturating a layer of lint or cotton, which 
is applied to the whole anterior and lateral aspects of the neck 



316 DISEASES OF THE EAR, NOSE, AND THROAT. 

and then covered with a thick layer of cotton. The underclothing 
should always consist of wool. 

Chronic Rheumatic Sore Throat. 

Synonym. — Gouty sore throat. 

Pathology. — This has generally passed under the name of 
gouty sore throat and is due to the same causes that operate to 
produce various rheumatic or gouty manifestations in other 
organs. There is undoubtedly an increased formation and a 
retention of uric acid in the body, and these processes, together 
with their resulting morbid phenomena, are discussed at length 
in the chapter on hay fever (page 222). 

Symptomatology. — This disease differs from acute rheu- 
matic sore throat principally in degree. There is not acute 
suffering except in exacerbations of the disease when it lapses 
into the acute form. It usually comes on at the same change- 
able seasons that excite the acute attacks, but may be present 
in greater or less conspicuousness throughout the year. In this 
case it is more troublesome during the winter months. 

There is a sense of discomfort, perhaps ill-defined, but 
annoying, in and about the throat, often extending to the larynx 
or even to the trachea. When these lower air-passages are 
involved, it is often in consequence of cold, damp, chilling 
winds from the northwest. Pressure over the larynx or the 
hyoid bone reveals tenderness and soreness of the parts, sug- 
gestive of perichondritis or periostitis. The patient is conscious 
of an indefinite sensation described as a constriction or an 
aching, which is increased by considerable use of the voice. 

The laryngeal mucous membrane is not generally involved 
to the extent of producing hoarseness or presenting positive 
indications of the disease on laryngoscopy. 

Diagnosis. — This disease must be differentiated from the 
simple inflammation of the throat and from tuberculosis, 
syphilis, and cancer. However, the spasmodic, intermittent, 
and characteristic history of this trouble ought to facilitate the 
forming of an opinion. The physical appearances are generally 
negative as compared with the malignant diseases which are 



DISEASES OF THE PHARYNX. 317 

distinguished by visible lesions. In the latter diseases we find 
the cachexia or constitutional condition indicated by the par- 
ticular infection in each instance. 

Prognosis. — If the rheumatic or gouty habit has not existed 
too long, or is not of too severe a type, the prospect of relief 
as the result of treatment is good. The disease is not dangerous. 

Treatment. — The internal medication consists of that just 
previously described for the acute form, with the addition of a 
prolonged use of lithium. This remedy should be taken in 
appreciable doses rather than in the so-called lithia-waters 
extensively advertised in the newspapers. These waters often 
contain so little lithia according to the admittedly-correct 
analyses that one must needs swallow the startling draught of 
six thousand gallons of water to get an ordinary dose of lithia. 
The most convenient preparation is a tablet of effervescent 
citrate of lithia containing 3 grains, made by Wm, R. Warner 
& Company. I have tried the various preparations, but have 
found none so satisfactory as this. Two or three of these are dis- 
solved in a large glass of water — the more water, the better — and 
taken once or twice a day for months in succession until the 
rheumatic or gouty habit is overcome. I have known of no 
serious disturbances following the protracted use of lithia in 
this form, although I have given it over very protracted periods. 
A few individuals are susceptible and have symptoms of stran- 
gury if too much is taken. Others do not use a sufficient 
quantity of water and have a slight gastric disturbance. 

The sufferers from this disease, like most other people, 
drink too little water to dissolve the waste-elements of the body 
and eliminate them. We flush the sewerage system of a city to 
increase freedom from infection ; but how much more important 
is it to flush the sewerage of the body and wash out the waste- 
products of tissue metamorphosis and prevent infection of the 
system by the results of decomposition. The success of the 
water-cures in these diseases lies largely in the amount of water 
passed through the body, taking up the debris of the tissues, 
dissolving out the urate of soda from the joints, the liver, and 
the more alkaline tissues, in which it is stored only to enter the 



318 DISEASES OF THE EAR, NOSE, AND THROAT. 

blood when it becomes sufficiently alkaline in reaction and then 
to rack the body with pains. 

The clothing should always be sufficient to keep the person 
as warm as comports with comfort, and wool is preferable to 
silk, for it is a more perfect protective against rapid changes of 
the temperature. Cotton or linen must never be worn next the 
skin. The bowels must be kept regular. 

If sensitive spots are detected in the throat or larynx, a 10- 
per-cent. solution of carbolic acid in glycerin can be applied to 
the painful area. The local anaesthetic effect of the carbolic 
acid affords relief without cauterizing the tissues, by the use of 
this combination. 



CHAPTER XXVIII. 

DISEASES OF THE PHARYNX, CONTINUED. 

Sore Throat of Measles, Scarlet Fever, and Small-pox. 

measles. 

The mucous membrane of the throat often participates 
to a large degree in the eruption of measles, and, although it 
generally is not severe enough to require special treatment, I 
have seen it so intensely involved as to necessitate as persistent 
efforts as the diphtheric throat. In this class of cases the mor- 
tality amounts to 80 per cent. 

If the throat is examined about the time the fever appears 
it is found to be hyperaemic, and this condition increases to a 
congestion by the third or fourth day of the fever when the 
eruption is noted. In the membranous form an exudation- 
occurs that closely resembles the false membrane of diphtheria. 
If this is removed, an uneven, raw-looking, ulcerating surface is 
found beneath. The inflammation and exudation cover the 
soft palate, uvula, tonsils, and posterior pharyngeal wall in 
severe cases. The swelling of these parts is great, the velum 
palati is paretic, swallowing is torturesome, and the tongue and 
general condition are indicative of a grave disease. The ulcer- 
ative process may extend deeply enough into the tissues to 
eventuate in abscesses. Instances of Eustachian tubal catarrh 
and middle-ear complications are numerous. 

The larynx is often invaded in measles, but generally only 
to the extent of setting up a catarrhal condition such as com- 
monly affects the trachea and bronchial tubes ; but, if the diph- 
theric form of measles affects the larynx, the outlook is a very 
discouraging one, for four out of five of these cases die. 

Treatment. — The simple catarrhal sore throat requires treat- 
ment principally to prevent middle-ear involvement. The meas- 
ures recommended for acute pharyngitis are sufficient, but the 
membranous form should be treated with as unremitting thor- 

(319) 



320 DISEASES OF THE EAR, NOSE, AND THROAT. 

oughness as diphtheria, the treatment for which is indicated 
here. (See chapter on diphtheria.) 

SCARLET FEVER. 

As in measles, so in scarlatina, the pharyngeal mucous 
membrane is generally concerned, but in the simple form of the 
disease the throat involvement is not serious. In the severe 
form the membrane becomes intensely injected and of a dark- 
red color. Infiltration of the tissues produces swelling that is 
apparent to the eye on inspection and even the neck may pre- 
sent a swollen appearance. The glandular bodies with which 
this region is so richly supplied — the tonsils and the parotid, sub- 
maxillary, and lateral cervical glands — may all be invaded by 
an intense phlegmonous inflammation with resulting abscesses. 

The throat may be inflamed even when the eruption of 
scarlet fever is absent. As in measles, the swelling and oedema 
involve the soft palate as well as the pharyngeal walls, and 
suppuration and abscesses may occur if the necrotic process 
extend deeply into the submucous tissues. Middle-ear diseases 
more often result from scarlatina than from measles, and the 
results are far more disastrous than from measles. Suppura- 
tion of the tympanic cavities with resulting granulations, polypi, 
extensive caries, and necrosis, as well as a high degree of 
deafness, are frequently attributable to scarlet fever. 

A malignant type of this disease occurs that takes on the 
form of diphtheria. The throat symptoms do not make their 
appearance until a week or longer or until the exanthem and 
fever have disappeared. Then the throat is attacked, the sub- 
maxillary glands swell, the throat is covered with a diphtheric 
membrane, a foul discharge takes place, and the breath acquires 
a fetid odor. The larynx is sometimes invaded, producing the 
croupy form of scarlatina. The glands at the angle of the jaw 
may suppurate and the resulting abscesses, breaking outward, 
leave scars at this point. 

The diagnosis is aided by the presence ol an epidemic, and 
doubt is set at rest by the appearance of the eruption. In the 
membranous form culture-tests for the presence of the Klebs- 



DISEASES OF THE PHARYNX. 321 

Loffler bacilli should be made to determine whether or not we 
have to deal with true diphtheria, and in the absence of bacte- 
riological facilities the disease, as far as the throat is concerned, 
at least, is to be treated on the theory that it is diphtheria. 

The prognosis in scarlet-fever sore throat, if this is a prom- 
inent feature of the disease, must be guarded, for the throat 
affection often causes death. In the simple form it is not danger- 
ous; but in the severe, or anginose, form about 25 per cent, die, 
and about 50 per cent, of the diphtheric cases prove fatal. 

Treatment. — Aside from general treatment, which is prop- 
erly left to general works on medicine, the throat should receive 
special attention when it gives promise of becoming seriously 
involved. In the first stage of the inflammation cold, in the 
form of an ice-bag (Fig. 78), may modify the intensity of the 
inflammation and avert or retard the tendency to suppuration. 
The throat-tablets and other remedies recommended in the treat- 
ment of acute pharyngitis are more effective than gargles. In 
the pseudomembranous form, which may prove to be a diph- 
theric complication, the treatment for diphtheria must be 
followed. 

SMALL-POX. 

. The pustular eruption of small-pox makes its appearance 
in the throat in many cases, and I have seen it extend forward 
to the buccal cavity. The amount of the throat eruption corre- 
sponds to the virulency of the attack. The swelling and inflam- 
mation may become sufficient to cause pain and difficulty in 
swallowing. The inflammation extends in many instances to 
the larynx and trachea, and the resulting oedema has caused 
suffocation and death. 

In mild attacks there is no danger ; but invasion of the 
larynx is a grave complication. 

Treatment. — The cleansing and disinfecting sprays followed 
by the protective and emollient and oily preparations given in 
Chapter XVIII are indicated. If the oedema extend to the 
larynx, scarification must be resorted to in order to prevent suf- 
focation, and indeed it may become necessary to intubate or 

21 



322 DISEASES OF THE EAR, NOSE, AND THROAT. 

perform tracheotomy. In the diphtheric form resort must be 
had to the treatment described in the chapter on diphtheria. 

Follicular Pharyngitis. 

Synonyms. — Folliculous, or granular, pharyngitis ; clergy- 
man's sore throat. 

Pathology. — There are two forms of follicular pharyngitis, 
— the hypertrophic and the exudative. In the first form the 
follicles are enlarged and stand out prominently upon the mem- 
brane, while in the second, or exudative, form there is a secretion 
of a light color, which may become dried and cheesy in con- 
sistence and appearance. In the hypertrophic condition the 
morbid changes are epithelial rather than follicular, but in the 
exudative form the follicular tubules are distended and their 
walls thickened, and chalky deposits are sometimes found within 
the follicles. 

In the case of public speakers the severe tests to which the 
vocal organs are put increase the demands on the glandular 
elements to furnish an extra amount of the lubricating secre- 
tions. This protracted exercise results in increased blood- 
supply and deposit of nutrient materials, or an excess of growth 
of the glandular tissues, and this, together with occlusion of the 
apertures of the follicles, account for their hypertrophic con- 
dition. Irritating discharges from the naso-pharynx serve to 
excite inflammation in the orifices of the follicles, resulting in 
their constriction or obliteration. 

Etiology. — It is not a simple matter to account for this 
disease, for it exists in young children who are not exposed to 
the irritants to which the disease is usually attributed : excessive 
use of the voice, the inhalation of dust, gases, smoke, etc. 
There seems to be an inherent tendency to a proliferation of 
cells in the mucosa. It is especially prevalent in those having 
the strumous diathesis. Old age seems quite exempt from this 
form of throat trouble, but presents the atrophic stage of 
pharyngitis. 

Symptomatology. — In the early stage of this disease the 
patient complains of dryness of the throat or a tickling sen- 



DISEASES OF THE PHARYNX. 323 

sation that occasions frequent efforts to relieve, and a slight, 
hacking cough. The voice assumes a husky quality and tires 
after speaking or singing a short time, and while using the voice 
transitory lancinating or shooting pains occur. 

The dry stage is followed by a mucous secretion which is 
often stained with pus or blood. The discharge is usually thick 
and tensile, and clings to the posterior pharyngeal wall or sticks 
to the posterior surface of the velum. If it is not too abundant 
it dries into scales or crusts. The membrane covering the back 
wall of the pharynx is studded with several spongy, red masses 
or is sometimes quite covered with them (Plate VI). They are 
in some instances punctated, appearing like little nipples ; in 
others they have broad bases, are fiat, and become coalesced in 
patches. Behind and external to the posterior faucial pillars 
their union forms a ridge extending upward and outward toward 
the Eustachian orifices. The blood-vessels are engorged and 
the veins are abnormally prominent. 

The tonsils are enlarged in a considerable proportion of 
these cases and the uvula is relaxed and tickles the tongue 
(Plate V). The membrane intervening between the follicles 
may be atrophied and of a grayish-white color that will convey 
an impression, at first sight, of pus. 

Diagnosis. — Cohen mentions the presence of ulcerated 
patches in this affection, which would render one liable to mis- 
take this for a syphilitic throat, but I do not remember to have 
encountered this condition. Eliminating the question of ulcers, 
which must be very rare, there is little likelihood of this being 
mistaken for syphilis or tuberculosis. 

Prognosis. — If let alone follicular pharyngitis may be ex- 
pected to invade the larynx and seriously affect the voice for 
speaking and ruin it for singing, or it extends to the Eustachian 
tubes and through them to the middle ears, resulting in hyper- 
trophic or sclerotic catarrh of these important organs. At last 
the history of this disease brings us to the fourth stage of throat 
catarrh, or atrophic inflammation, resembling atrophic rhinitis. 

Treatment.— The physician does not often enjoy the op- 
portunity of treating this disease in its early stages, for the 



S24 DISEASES OF THE EAR, NOSE, AND THROAT. 

symptoms are not urgent enough to suggest the need of medical 
services. As in the other inflammatory processes, cleanliness is 
the first prerequisite. The alkaline and antiseptic washes and 
the oleaginous sprays discussed in the chapter on those subjects 
are useful here. After perfectly cleansing the nose and throat, 
for this is the first step in the treatment, the follicles, two or 
three at a sitting, should be reduced by the application of 
chromic acid, London paste, or — better still — the galvano- 
cautery. If the acid or paste is used, great caution is necessary 
not to let it drop into the larynx or oesophagus or spread upon 
the surrounding membrane. The chromic acid is applied in the 
form of a bead of the crystals fused upon the platinum wire- 
loop applicator (Fig. 66). The London paste is applied in small 
particles so that they will adhere like minute spots of plaster on 
the surfaces of the follicles. 

The galvano-cautery is the most satisfactory means of erad- 
icating the tumefied follicles (Figs. 132, 133, and 134). The 
long electrode is chosen according to its fitness for the particu- 
lar condition present and applied to the apex or centre of the 
follicle before the current is turned on. Then the circuit is 
closed for an instant until the tumefaction is burned so as to de- 
stroy it to a point a little below the surface of the adjacent mem- 
brane. On the following day the hypertrophied tissue is seen 
to have given place to a gray surface that will be cast off as a 
slough in about a week. By repeating this process a number 
of times all the enlarged follicles can be dispersed. In the 
meantime cleansing, soothing, and protective remedies should 
be applied in the form of sprays, such as a 3-per-cent. solution 
of camphor-menthol, benzoinated lavolin, and a 4-per-cent. 
solution of eucalyptol in lavolin. These should be used once 
or twice a day, preferably at bed-time and on rising in the 
morning. 

General treatment is demanded by a uric-acid diathesis to 
prevent rheumatic or gouty attacks in the throat, and, if the 
digestion is faulty or the eliminative functions are impaired, 
remedies must be addressed to these conditions. The local 
treatment is often aided by tonics and alteratives. 






diseases of the pharynx. 325 

Membranous Sore Throat, Non-diphtheric. 

Synonym. — Simple membranous sore throat. 

Pathology. — There occurs occasionally a form of sore throat 
characterized by an exudate that covers the pharynx and fauces, 
and extends upward and forward toward the hard palate on its 
inferior surface, resembling the diphtheric membrane. This is 
the result of an herpetic eruption in the throat, the blisters of 
which rupture and cover the membrane with their contents. 

Etiology. — The cause of this affection is not known, but it 
is more prevalent during epidemics of diphtheria than at any 
other times. 

Symptomatology. — The initiatory symptoms are very like 
those of diphtheria, except that they are of diminished intensity. 
There are chills; fever of 101° or 103° F. ; rapid pulse ; dirty, 
indented tongue ; dry throat, with burning pain ; and difficulty 
of swallowing. Blisters are often found coincidently on the 
lips. 

In the beginning of the attack the membrane of the throat 
is of a deep-red color dotted with follicles that are inflamed or 
pustular in character. As these pustules rupture and their con- 
tents escape over the surrounding surface the appearance of a 
false membrane is given to such patches. The seat of each 
ruptured pustule may become an ulcer, and these grouped 
together present irregular areas of ulceration. 

Diagnosis. — Simple membranous sore throat may be con- 
founded with diphtheria, but it is not so grave a disease. Al- 
though it may be ushered in by symptoms simulating diphtheria 
and with a high fever, generally all the symptoms are of a 
milder grade. The simple membrane is much thinner, — indeed, 
one can almost discern the mucous membrane beyond, — while 
in diphtheria the false membrane is three or four millimetres 
thick and closely adherent to the surface beneath. In the 
simple disease the membrane is easily detached by means of 
cotton on a carrier, leaving a smooth surface, while detachment 
of diphtheric membrane reveals raw, uneven, ulcerating tissues 
exposed to view. Bacteriological examination in diphtheria 



326 DISEASES OF THE EAR, NOSE, AND THROAT. 

shows the presence of the Klebs-Loffler bacillus, which is the 
germ of this disease, while the tests of the simple form are 
negative. The sputa and sections of the membrane should be 
submitted to the culture-tests in this or any other disease in 
which diphtheria is suspected. It has become an easy matter 
in large cities like Chicago, where there are laboratories for such 
purposes and the health department of the city government 
conducts such experiments. 

Prognosis. — This disease in itself is not dangerous, but it 
should not be forgotten that true diphtheria sometimes is en- 
grafted upon it, especially during epidemics. 

Treatment. — During the first stage, when the fever is high, 
guaiacol diluted one-half with glycerin and applied with cotton 
on a holder mitigates the symptoms, and is indicated on account 
of its effect in reducing the temperature. It is best not to use 
it in full strength, for it has sometimes appeared to have a 
destructive effect on the mucous membrane, and I have found 
on the day following its application an ulcerated surface cor- 
responding to the area touched with the pure guaiacol. Hy- 
drogen dioxide should be sprayed into the throat every few 
hours, the intervals depending on the rapidity with which the 
false membrane is formed. But it is not necessary to use it fre- 
quently if it cause much smarting and burning, for the gravity 
of the disease does not warrant it. If considerable pain is pro- 
duced by the H 2 2 , it probably contains too large a proportion 
of acid and requires dilution. The blue litmus-paper will show 
this. Ingals prefers the following pigment : Morphias sulphatis, 
gr. iv ; acidi carbolici, gr. xxx ; glycerini, fgj ; to which he adds 
30 grains of tannin when an astringent is required. 

Inhalations and sprays are more easily applied and cause 
less discomfort than swabs and pro bangs. I have seen much 
relief afforded by adding 10 drops of pure camphor-menthol to 
a pint of hot water for the patient to inhale through the mouth. 
An ordinary tea-kettle or small tea-pot or coffee-pot can be 
pressed into service for this purpose. The nozzle is covered 
with several thicknesses of cloth, not including the opening 
itself, so as to prevent burning the lips, and the end of the 



DISEASES OF THE PHARYNX. 327 

nozzle is taken between the lips while the steam impregnated 
with the fumes of the medicine is drawn gently into the throat. 
This has given good results in other forms of sore throat. Car- 
bolic acid in glycerin, of 5- or 10-per-cent. strength, will deplete 
the blood-vessels and anaesthetize the mucous membrane suf- 
ficiently to relieve pain. Sprays of eucalyptol, camphor-menthol, 
or salol in 3-per-cent. solutions — after the alkaline antiseptic 
sprays already given in Chapter XVIII — have a refreshing 
effect. 

The general treatment, diet, and hygienic and prophylactic 
measures appropriate to this disease are the same as those recom- 
mended in the treatment of coryza and acute pharyngitis. 



CHAPTER XXIX. 

DISEASES OF THE PHARYNX, CONTINUED. 

Diphtheria. 

Unlike the sore throats of scarlatina, measles, and small- 
pox, in which a pharyngeal manifestation is not a necessary 
element of the disease, or in which, if it exist, it is merely 
incidental to a constitutional malady, in diphtheria we recognize 
a veritable throat affection with systemic infection. The impor- 
tance of the disease and the advancements recently made in its 
pathology and treatment warrant an extended presentation of 
the subject. 

Since the discovery of the microbe which causes diphtheria 
by Klebs, in 1883, the method and nature of the disease have 
been illuminated by the researches of Lofrler, Roux, Welch, 
Prudden, and others. 

Pathology. — In true diphtheria there is always present in 
the membranous deposits in the throat a micro-organism that is 
not found in like exudates of other diseases. This microbe is 
easily differentiated from others and can be isolated and prop- 
agated in culture-tubes. When animals like guinea-pigs and 
rabbits are inoculated with this organism the disease which 
produced the microbe is reproduced in the susceptible animals. 
Extensive experiments and studies by scientific observers have 
conclusively demonstrated that this disease is one of local origin 
with constitutional phenomena depending upon the absorption 
of a poison generated by the specific micro-organism. The 
false membrane of diphtheria abounds in these microbes in its 
superficial layers, but they are not found in the stratum next 
the mucous surface, and generally not in the mucous membrane 
itself. The poisonous principle evolved by this microbe is com- 
parable to the venom of serpents, and in this connection it is 
instructive to observe that in contrast to this deadly microbe 
another is found identical with it in biological and morphologi- 
(328) 



DISEASES OF THE PHARYNX. 



329 



cal characteristics, but lacking in the power to destroy the lives 
of susceptible animals. This has been termed the false, or 
pseudodiphtheric, bacillus. Concerning the variations in the 
pathogenic properties and powers of these bacilli, Abbott says, 
in the Medical Neics for November 17, 1894 : " It was observed 
that the genuine, virulent diphtheria bacillus was liable to 
fluctuate in the degree of its pathogenic properties, at times 
possessing these to such an extent that, when inoculated into 
guinea-pigs, death resulted in from thirty-six to forty-eight 
hours, while again the period of inoculation was much longer, 




Fig. 152.— Diphtheria Bacilli. (After Krieger.) 

Culture on agar-agar, twenty-four hours old : stained in alkaline methylene-blue 
magnified 1000 time<. 



often reaching five or six days, and in not a few cases organisms 
were obtained from undoubted cases of diphtheria that failed to 
give more than a temporary local reaction when inoculated into 
these animals." 

The micro-organism of diphtheria is named the Klebs- 
Lofner bacillus (Figs. 152 and 153), after the scientists who 
have brought to light the germ that causes untold suffering 
and a vast waste of human life. When this bacillus comes in 
contact with a mucous membrane or with abraded skin an 
inflammation is excited. The conditions then are favorable for 



330 DISEASES OF THE EAR, NOSE, AND THROAT. 

the development and propagation of bacilli, — warmth and 
moisture, — and, while the microbes themselves do not enter 
into the lymph or blood circulation, their poisonous product does. 
In this manner an infection of the whole system takes place, 
— a toxaemia of specific type. This poison introduced into the 
blood of guinea-pigs and rabbits in minute quantities produces 
death, and its potency is retained for long intervals in a vacuum. 
According to Yersin and others, the bacillus itself is not viru- 
lent, but the poisonous product of the microbe is the material 



% . -**« l#v 



it 






•ts 






i 






^ 






Fig. 153. — Diphtheria BacHiU. (After Krieger.) 

Culture ou blood-serum, prepared as Fig. 152 ; magnified 1000 times. The short form 

8 resented in this specimen is due to their rapid multiplication. Some of the germs are 
istinguished by a club shape, which is considered characteristic of this species. 

that causes paralysis in sheep and dogs, and death in rabbits. 
A similar bacillus is also found in the mouths of individuals 
who have never had diphtheria and who have not been exposed 
to it. To all appearances this is the true Klebs-Lofrler bacillus 
deprived in some way of its virulency. It may have become 
modified or attenuated, but whether its poison-producing powers 
can become revivified is not known. These facts demonstrate 
that practically two diseases have formerly passed under the 
name of diphtheria, just as previously to the present century 
scarlatina and measles were supposed to be identical. 



DISEASES OF THE PHARYNX. 331 

In true diphtheria the infection and toxaemic condition are 
produced by the Klebs-Lofner bacillus, but in false diphtheria 
this bacillus is absent or is changed in character, and in its place 
are found the streptococcus longus, the streptococcus pyogenes 
(Fig. 154), and the staphylococcus. 

False diphtheria is a much milder disease than the true 
form and is far less frequently productive of paralysis. Although 
these two forms of the disease cannot be differentiated except 
by bacteriological methods, Baginsky, Virchow, Henoch, Smith, 
and others recognize the dual character of the disease. In the 










Fig. 154.— Streptococcus Pyogenes. (After Krieger.) 

Streptococci and leucocytes of human pus; stained in gentian-violet: magnified 1000 
times (Pfeiffer and C. Fraenkel). 

true form the streptococcus and staphylococcus are often found 
associated with the Klebs-Lofner bacillus and even the internal 
organs are invaded by the cocci, where the bacilli of true diph- 
theria do not penetrate. The cocci have been found in the 
lungs and kidneys as well as in abscesses of the neck. 

The bacillus of true diphtheria is possessed of remarkable 
vitality and may convey the disease after months and even years 
of latency. D'Espine and others found their potency unim- 
paired in cultures of sixteen months. Cases are on record in 
which infection occurred from clothing and other articles after 



332 DISEASES OF THE EAR, NOSE, AND THROAT. 

as many as twenty years, and these are authenticated by ob- 
servers of undoubted competency and credibility. 

Diphtheria usually attacks persons under the age of 30 
years, but may occur at any period of life. Its relative 
frequency in the very early years would almost justify the desig- 
nation of a disease of children. Out of 1512 cases in one statis- 
tical table I find that 1309 occurred in children under 6 years 
and only 203 from 6 to 17 years. It has been observed very 
infrequently in infants under 6 months old ; but at this age the 
organism appears to be nearly immune against this disease. 

The period of incubation varies greatly, there being as 
wide a margin as from one to twenty days. In animals directly 
inoculated the variation is only from half a day to three days. 
The sooner the disease makes its presence known, the more 
virulent the type of attack. When the onset is slow and slug- 
gish it seems to indicate either the modification or attenuation 
of the infecting germ or the strong power of resistance of the 
system. 

Etiology.— Diphtheria is not a sporadic disease, since it 
cannot arise in a body independently of any extraneous cause. 
It can reproduce, but cannot produce, itself. The disease orig- 
inates in any individual in the following manner : The specific 
micro-organism known as the Klebs-Lofrler bacillus gains lodg- 
ment upon the mucous membrane or denuded skin. There it 
grows and multiplies, and during this development of cultures 
of the germ a poison is produced that is chemically analogous 
to the venom of serpents, and the analogy may be extended to 
include its virulency. The resulting pathological manifestations 
are a reproduction of the disease whence the infecting germ was 
derived. An exposure of a susceptible person to the specific 
microbe for only an instant may be sufficient to insure its recep- 
tion upon a favorable soil, and so rapid is the process of propa- 
gation and toxaemia that a few hours — or days, at most — 
witness the development of this plague of nations. 

Abbott, in the Medical News for November 17, 1894, 
speaking of the Klebs-Lofrler bacillus, pithily puts his views in 
these words : " If this agent is present, diphtheria exists ; if it 



DISEASES OF THE PHARYNX. 333 

is absent, then the local conditions and constitutional manifes- 
tations must be attributed to some other cause, and the disease 
is not diphtheria." The vitality of the bacillus, extending over 
many months or years, seems to insure the enduring nature of 
this decimator of communities. This is not an exaggerated 
characterization, for I have been in an epidemic that has literally 
annihilated family after family of children until the population 
was dazed by the devastation. 

Contact of persons with those who are, or have been, suf- 
fering with diphtheria is not necessary to constitute exposure. 
Merely the inhalation of a patient's breath, or being in the 
same room, or being in the presence of one who has been in 
such a situation and who may carry the infection in his cloth- 
ing, or handling a book between the leaves of which the germs 
may have found their way, may result in communicating the 
disease. The bearing of these facts upon the use of library 
books and the antiquated form of kissing the bible in courts 
and societies is too apparent to need elucidation. 

These germs naturally harbor where millers, moths, and 
molds thrive most. Dark, damp, badly-ventilated, and filthy 
places seem to be their appropriate habitat. It is commonly 
believed that the sewers of a city are the conveyors and dis- 
tributors of this poison to the people. Unless the sewer-traps 
are perfect and the sewers abundantly flushed, it is evident how 
the houses along the line of a sewer-system may become, one after 
another, the recipients of a poison entering farther up the stream. 
These microscopical germs are disseminated by vapors and 
winds and penetrate our homes with escaping sewer-gas. This 
view is substantiated by the fact that the death-rate from diph- 
theria is twice as great in cities as in rural districts, according to 
our vital statistics. 

The subtile nature of this microbe and its fondness for its 
victims and its vitality and power of propagation are suggestive 
of the multitudinous ways of infection and of the necessity of 
unceasing vigilance to escape it. One never knows when a child 
in school or in a public conveyance may not be sitting beside a 
diphtheric individual, and it seems as though no argument is 



334 DISEASES OF THE EAR, NOSE, AND THROAT. 

needed to show the absolutely dangerous character of the uni- 
versal habit of kissing children, who, in fact, are much more 
susceptible to this deadly disease than the adults who expose 
them. 

Surgeons have contracted diphtheria and many have lost 
their lives by having a particle of the membrane or discharges 
from a patient's throat coughed into their eyes or upon their 
lips or by receiving it upon an abraded skin surface. When 
making examinations of the throat they have forgotten either 
to wear protecting glasses over their eyes or to keep to one side 
of the line of the column of air expelled by coughing. 

The lower animals are subject to attacks of diphtheria. 
Pigeons, turkeys, and cats have communicated it to the human 
family in various authenticated instances. Hence the unappre- 
ciated danger of allowing children to pet and caress sick cats is 
apparent. Rabbits and guinea-pigs are susceptible to the diph- 
theric virus, and cows' milk has been known to convey this 
disease, as it does scarlatina. 

Symptomatology. — There is a very wide margin of varieties 
in both the local and systemic manifestations of diphtheria. 
The disease may appear in a very mild form or there may be a 
severe throat imfiammation with distressing local evidences and 
alarming and fatal constitutional involvement. The period of 
incubation is generally from two days to a week, and is charac- 
terized by sensations of chilliness, waves of heat, headache, weari- 
ness or sleepiness, and depression of spirits. Following these 
premonitory symptoms are more pronounced ones announcing 
a serious disturbance of the digestive and circulatory systems. 
Loss of appetite, nausea, vomiting, and diarrhoea occur, accom- 
panied by thirst and increase in the force and frequency of the 
heart's action. Heat and dryness of the throat, stiffness or sore- 
ness in the muscles concerned in the act of swallowing, which is 
painful ; and tenderness on pressure under the angle of the jaw 
indicate the localization of the pathological process in the throat. 

The temperature rises to 101° F. in the first stage and 
sometimes as high as 104° F. Adults are more likely to com- 
plain of headache and backache than children. An erythem- 



DISEASES OF THE PHARYNX. 335 

atous eruption occasionally appears during the first stage. 
Inspection of the throat within the first few hours of the 
seizure reveals a reddened, swollen condition of the mucous 
membrane of the soft palate and tonsils. All the symptoms 
are not present in all the cases. One must expect to find 
some of these lacking, and a description that will accurately 
fit one case may vary widely of the mark if applied to the 
next. But we would best consider typical cases. 

The second stage is that in which the false membrane is 
formed and the presence and proliferating powers of the diph- 
theria bacillus are demonstrated. The first appearance of this 
disease-label — which is usually within the first day or two of the 
onset — is a thick, yellow secretion, which can be seen covering 
the tonsils. A little later a yellowish-gray or a dirty, grayish- 
w 7 hite, false membrane is seen to have made its appearance in the 
fauces and pharynx, increasing in thickness and extent until 
little can be seen but this background to a painful picture. If 
pieces of this adventitious tissue are detached from the mucous 
membrane, to which it is closely adherent, the latter is seen to 
appear rough, raw, granular, and bleeding. All the group of 
glands in the vicinity of the throat become indurated and 
sensitive. 

The high temperature usually falls after the full develop- 
ment of the exudate in the pharynx, and may reach the normal 
on the fourth or fifth day. Decomposition of the secretions of 
the throat causes an offensive breath, which may often be ob- 
served the instant one enters the patient's room. The profound 
impression of the diphtheric virus on the circulatory system is 
evident from the feebleness of the pulse, which is compressible 
and abnormally rapid or slow. The kidneys participate in the 
general systemic disturbance, although the diphtheria bacillus 
itself does not penetrate to them; and the urine is decreased, 
high-colored, and rich in urea, and often in albumin also. 

About the third or fourth day there may occur an extension 
downward of the disease into the larynx with unmistakable 
signs of a serious complication. The respiration is harsh and 
embarrassed and a dry cough reveals the hoarseness of the 



336 DISEASES OF THE EAR, NOSE, AND THROAT. 

voice. Increasing constriction of the laryngeal cavity and 
narrowing of the air-tnbe from the pharynx to the trachea is 
evidenced by distressing dyspnoea, blueness of the lips and 
finger-nails, pufflness of the face, and increasing dullness of the 
intellect until unconsciousness and fatal coma come to the 
sufferer's final relief. 

Other complications result from an extension of the disease 
to the nasal cavities, followed by a thin, yellow or dark, foul dis- 
charge from the nose, excoriating the skin about the nostrils and 
on the upper lip. The invasion of the nasal ducts may lead to 
involvement of the eyes, or extension to the Eustachian tubes 
may presage invasion of the middle ears with the train of con- 
sequences following in the wake of a suppurative middle-ear 
inflammation of a diphtheroid type. 

The third stage results in resolution or death. This period 
of the disease begins at about the end of a week, when all the 
racking symptoms may gradually melt away with the loosening 
and exfoliation of the false membrane. The general condition 
shows a refreshing improvement, — a sunshine of calm succeed- 
ing a physical storm. The fever is gone, the pulse drops to the 
normal rate, painful swallowing disappears, desire for food 
returns, the kidneys and skin perform their functions naturally, 
and all but the strength may now return to par. 

Unless a relapse occurs, or the heart has been too pro- 
foundly implicated so as to incur the liability of syncope, or 
diphtheric paralysis follow the attack, the patient pursues a 
normal course to complete recovery. 

In case the infection is of an intensely virulent type and 
finds the powers of resistance weakened, the system yields to 
the irresistible invasion of the virus and succumbs to coma and 
death. 

This is the natural history of a typical attack of diphtheria 
uninfluenced by the efforts of man to avert or modify its progress. 
Between this type and simple membranous sore throat there are 
great variations in the virulency of the infection and its mani- 
festations. 

Diagnosis. — Simple membranous sore throat and ulcerative 



DISEASES OF THE PHARYNX. 337 

tonsillitis are the most likely to confuse the practitioner in differ- 
entiating between diphtheria and other pharyngeal affections ; 
but the exudative form of sore throat in measles and scarlet 
fever also closely resembles true diphtheria. The presence of a 
diphtheric epidemic, the rapid development of the symptoms, 
and the closely adherent, leathery membrane are definite diag- 
nostic features. The membrane of the other diseases is thin 
and easily wiped off with cotton, leaving generally a smooth 
membrane beneath, instead of a rough, ulcerating, or bleeding 
surface. The absence of the skin-signs of measles, scarlatina, 
and erysipelas aid in excluding those diseases, although very 
exceptionally an erythematous rash occurs in the first hours of 
diphtheria. 

From throat inspection alone it is impossible to distinguish 
between diphtheria and'other forms of pharyngitis before either 
a false membrane forms or an eruption appears, so that it is 
then necessary to be conservative in expressing an opinion, and 
to treat the case as though it were expected to eventuate in 
diphtheria. 

A positive diagnosis is possible if a bacteriological exami- 
nation prove the presence of the Klebs-Loffler bacillus. Other 
microbes may be present and embarrass the results of treatment, 
but the nature of the infection is established. It must not be 
forgotten, however, that another micro-organism identical with 
the Klebs-Loffler bacillus, to all appearances, is sometimes 
found, but differing from it in that it produces a milder affec- 
tion. The disease characterized by this microbe should be 
termed " diphtheroid," analogously to the formation of the term 
" typhoid " from typhus. As soon as any symptoms exist to excite 
a reasonable doubt as to the possibility of the disease being 
diphtheria, the secretions, and especially any available false 
membrane from the throat, should be secured in a perfectly- 
clean, sterilized test-tube and submitted to the microscope and 
culture-test by a competent bacteriologist whenever it is possible 
to do so. Where it is not practicable, the treatment should be 
conducted on antidiphtheric principles until a positive diagnosis 
can be rendered. 

22 



338 DISEASES OF THE EAR, NOSE, AND THROAT. 

Prognosis. — This is one of the most fatal of the diseases 
that afflict humanity; but, in view of all the evidence adduced 
during the past year, it is evident that the death-rate has been 
reduced since the introduction of serum therapy. Notwith- 
standing this, the physician should always recognize the possi- 
bility of a fatal termination even under the most favorable 
circumstances for treatment. If the infection is of a mild type 
and the resisting-powers of the patient are strong, the chances 
of recovery are good. The majority of such cases get well ; 
but one cannot tell when such a case may take on a virulent 
form of the disease that rapidly leads to collapse. 

Patients often succumb in a day or two after the seizure, 
and the majority of fatal cases die by the fifth day. In very 
young children, at the age when tenacity upon life is feeble, 
this disease rages with a fearful mortality. Signs of the gravity 
of an attack are invasions of the nose, ears, larynx, and trachea ; 
haemorrhages ; purpuric eruption; suppression of the urine; vom- 
iting, and diarrhoea. In laryngeal stenosis without intubation 
or tracheotomy the death-rate reaches the appalling figure of 
95 per cent. A large number of sudden deaths are attributed 
to heart-failure. 






CHAPTER XXX. 

DISEASES OF THE PHARYNX, CONTINUED. 

Diphtheria, Continued. 

Treatment. — Since diphtheria is primarily a local disease 
with secondary constitutional infection, in this respect com- 
parable to syphilis, we will take up the consideration of medic- 
inal treatment in the logical order suggested by the sequence 
of the phenomena that constitute its history: (1) local and (2) 
constitutional treatment, — both the classic method and the 
modern serum therapy. But coincidently with the beginning 
of treatment certain preliminary precautions must be observed 
for the conduct of any given case to a successful issue, and also 
for the protection of other members of the family and the 
community. 

In addition to observing the patient's pulse, temperature, 
and respiration, and other physical signs and symptoms, the 
throat and nose should be examined in such a way as to avoid 
the possibility of the physician himself becoming infected. In- 
stead of occupying a position immediately in front of the pa- 
tient while inspecting the throat he should be at one side and 
on the alert to dodge any of the discharges from the throat that 
may be expelled by a sudden, explosive cough. Otherwise a 
lodgment of the venomous secretion or a particle of false mem- 
brane in the doctor's eye or on his lips may cost him his life. 
Moreover, cases have occurred in which the expulsion of the 
virus has resulted in its Ian dins: in the examiner's beard or on 
his clothing, and the communication of the disease with deadly 
effect to members of his own family or to other patients. The 
practice of holding a small pane of window-glass between the 
patient's mouth and the physician's face is an excellent one. 

The medical attendant of a diphtheric case would best re- 
move his coat and vest and wear an operating-gown reaching 
from his neck to his feet, or, in lieu of this, a sheet pinned 
about his neck and enveloping the person to the feet. After the 

(339) 



340 DISEASES OF THE EAR, NOSE, AND THROAT. 

examination, his hands, face, and beard should be washed with a 
solution of bichloride of mercury, 1 to 10,000. The instruments 
used should be boiled over a very hot fire in a solution of car- 
bonate of sodium — an ounce to the pint of water — to disinfect 
them. All utensils, handkerchiefs, napkins, etc., used by the 
patient must be treated in the same manner. 

Assuming that the examination reveals the presence of 
diphtheria, or even a condition that excites a suspicion of that 
disease, the patient must at once be isolated from all except the 
medical attendant and the nurse. If possible, one or two rooms 
should be selected away from any cellar or basement, above the 
ground-floor and so situated as to admit the sunlight and an 
abundance of fresh air. All carpets, rugs, window-curtains, 
pictures, draperies, upholstered furniture and unnecessary arti- 
cles must be removed before the patient is admitted into this 
room. Without exposing the sick one to draughts of air, free 
ventilation should be effected from the tops, not the lower parts, 
of windows. The temperature should be kept uniformly at 70° 
to 74° F. The body-clothing must be such that children 
cannot expose themselves to cold at night, and this rule should 
be observed also at all times, with children especially, who 
ought to wear union-suits by day and night-drawers at night. 
These consist (the first) of woolen shirt and drawers in one 
piece and (the second) of cotton-flannel or cotton suits made in 
the same way. The woolen suits are to be used in winter and 
the cotton-flannel for cool and the cotton for hot weather. The 
drinking-water must be pure. If there is reason for the slight- 
est suspicion of the purity of the water it should be boiled for 
fifteen minutes and then chilled, not by placing possibly-infected 
ice in it, but by setting it covered in a cold, pure atmosphere in 
winter or surrounding it with ice in hot weather. Pure water 
made cold by this means is safer than the ice sucked as recom- 
mended by many writers, since freezing does not destroy disease 
germs. 

The drainage of the house should be inspected to ascertain 
if cess-pools, stagnation, or faulty sewer connections are respon- 
sible for the sickness. All communication between the outside 



DISEASES OF THE PHARYNX. 341 

world and the patient must be forbidden, except through the 
physician and the nurse. In order that the contaminated air of 
the sick-room may not infect the adjoining apartments, a sheet 
should be saturated with a 5-per-cent. solution of carbolic acid 
and hung over the door-way of the chamber. A valuable anti- 
septic procedure is to have the bedstead, floor, and walls washed 
daily with a solution of mercuric bichloride, 1 to 10,000. One 
to 20,000 parts of water will destroy bacteria in ten minutes. 

The physician's duties do not end with giving instructions. 
He, himself, must often insist on their observation and person- 
ally superintend or execute his own orders if he would save his 
patient's life. As an illustration of the indifference of the aver- 
age family to the commonest sanitary regulations I will adduce a 
single instance: Upon being called to see a girl of 17 years, I 
found sufficient clinical evidence to warrant pronouncing her 
ailment diphtheria. She was lying in a bed in a large, but 
dark, damp, and apparently musty room. On inquiry it de- 
veloped that her brother and father had died of the disease in 
the same room and in the identical bed. I immediately asked 
to be shown the rooms on the floor above, and selected two 
adjoining apartments extending the width of the house, so that 
windows admitted sunlight and air on opposite sides. I directed 
all the contents of these rooms to be removed, excepting nothing 
but a bed, a table without a spread, and a chair without up- 
holstering. Promise was exacted that the patient would be 
removed to these chambers without delay. On the following 
day I found the patient where I had left her, and worse. Xo 
time was lost in informing the family that I would at once 
withdraw from the case, and that I would not make another visit 
or prescribe for the patient at the present one unless they imme- 
diately removed her to the selected apartments. They had 
decided that it would inconvenience them to do so, but lost no 
time in complying with my demands. Thorough antiseptic 
measures were adopted, such as had not been employed in the 
cases of the brother and father. Another younger child, a 
sister of the patient, soon was suffering from the same disease. 
She was subjected to the same rigid hygienic measures. Both 



342 DISEASES OF THE EAR, NOSE, AND THROAT. 

children recovered. One had abscesses of the neck, but no 
permanent bad results further than scars indicating the points of 
incision. Father and son died in the same room, in the same 
bed, with the surrounding conditions described. The two 
sisters recovered under conditions made as favorable as possible. 
Had they been kept in the dark, damp, musty, infected atmos- 
phere of the double-death chamber, I predicted that the under- 
taker would soon follow my footsteps. Measures that seem 
imperative and even harsh may sometimes be absolutely neces- 
sary to the patient's welfare and the doctor's conscience and 
reputation. 

It is a great advantage to have a skilled nurse to faithfully 
and intelligently execute the physician's directions. She will 
best carry out all the modern methods of care of the sick as 
perfected in our great hospitals. She will be prepared — as no 
untaught person can be — to observe the aseptic and antiseptic 
teachings of advanced medicine. Nothing that leaves the diph- 
theric patient, and that is capable of bearing infectious material, 
should escape a most thorough system of sterilization. Instead 
of napkins or handkerchiefs, cloths should be used to receive 
the matters expectorated, or discharges from the nose, etc., and 
these should be burned with the most scrupulous care that not 
a rag is left. The importance of this and the disinfection of 
sputa is plain enough when we reflect that flies are attracted to 
such refuse, after visiting which they cultivate the acquaintance 
of your susceptible nose, lips, and eyes, or any point of skin 
denuded of its epidermis, and there inoculate your infectious 
point. Cats prowl around the backyard, into which cloths 
soiled by the diphtheric discharges are thrown. These cats 
contract the disease and distribute it throughout the neighbor- 
hood. Dame Nature, in an angry mood, seems to have exercised 
all her cunning and ingenuity to devise unsuspected ways and 
intricate and invisible means for the prolific production and 
wide dissemination of the germs of this fatal plague of the 
throat. Such considerations led J. Lewis Smith to say : " The 
day will probably never come when we can say of diphtheria, as 
we can of small-pox, that it is virtually suppressed." 



DISEASES OF THE PHARYNX. 343 

The sputa should be disinfected, before removal from the 
patient's chamber, by pouring over it enough of a solution of 
bichloride of mercury — 1 to 1000 — to entirely cover the dis- 
charges. This should remain in the receptacle at least a half- 
hour and be agitated several times to bring all portions of the 
ejecta into contact with the disinfectant. Deodorizing and dis- 
infecting medicaments are volatilized in the room, much to the 
patient's comfort. I have observed excellent effects from melting 
menthol crystals in a teaspoon over a flame until the air was 
comfortably impregnated with the fumes. When the nose was 
involved I have taken the hot steaming liquid to the bedside 
and held it where I could blow the fumes over the bed toward 
the patient's face so that he would inhale a considerable quantity 
of them through both the nose and throat. His eyes are kept 
closed, and if not too great heat is used so as to make the fumes 
too dense, without any irritating effects, his nose and throat are 
benefited. If the throat is entirely covered by a thick mem- 
brane, of course no fumes reach the mucous coat beneath. 
J. Lewis Smith uses as a prophylactic the fumes of the following 
prescription : ly Olei eucalypti, acidi carbolici, aa 5j ; tere- 
binthinse, S viij . " Add 2 tablespoonfuls of this mixture to 
1 quart of water and allow it to simmer constantly near the 
patient in a vessel witli a broad surface, as a tin or zinc wash- 
basin, a vessel with a broad surface being needed so that it will 
not take fire. The vapor produced is strong and penetrating, 
but not unpleasant." Pynchon uses parching or burning coffee 
as a deodorizer. 

Local Treatment. — There are remedies that exert a solvent 
action on the false membrane when the latter is macerated in 
them for a considerable time, and this fact has led to their use 
as gargles and local applications by means of swabs and sprays. 
Some of these remedies have too slow and feeble an effect to be 
of efficient use in the throat. Others exert a decided and per- 
ceptible influence in dissolving the exudate both without and 
within the body. Such, for example, is sulphocalcin, to which 
my attention was first attracted by William C. Wile several 
years ago, at a meeting of the Mississippi Valley Medical 



344 DISEASES OF THE EAR, NOSE, AND THROAT. 

Association, to which he reported a large series of diphtheric 
cases in which unusual success had attended the topical applica- 
tion of this remedy. I then introduced it into my practice, and 
am able to confirm Wile's statement of the solvent properties of 
this preparation. In a letter recently received from the doctor 
he re-affirms his previous statements, and says his experience 
during the intervening years has been as satisfactory in the use 
of the drug as his first reports indicated. 

My method of employing the liquid is as follows : Absorb- 
ent cotton is twisted firmly on a long cotton-carrier curved at 
the roughened end so that it is impossible for the pledget to 
drop off into the throat. This is dipped into the fluid and 
pressed against the side of the small container, which should 
have a wide mouth. After pressing out all the surplus so that 
none will squeeze out and run down into the larynx, the medi- 
cated cotton is brought into contact with all the surfaces of the 
false membrane, making sure that the latter is wet with the 
sulphocalcin. The cotton is then burned. This treatment is 
repeated as often as is necessary to keep the membrane dissolved 
and the throat clear of it. At first it has sometimes been neces- 
sary to have the nurse apply it every fifteen minutes, lengthening 
the time between the treatments, as the membrane becomes less 
rapidly formed, to a half-hour, an hour, or two or four hours. 
When no false membrane re-appears the remedy is discontinued. 
The solvent effects of this treatment are so apparent that I 
wonder at its not having come into more general use. Its disa- 
greeable odor is an unfortunate feature. 

In the British Medical Journal of recent date Lennox 
Browne speaks of sulphurous acid as being an efficient germi- 
cide that acts systemically as well as locally with good results. 
I have often applied the sulphocalcin pure, and always do 
when the false membrane is thick enough to prevent the remedy 
from coming into actual contact with the mucous surface ; but, 
when the exudate is reduced to such a state of thinness as to 
allow the drug to penetrate to the mucous membrane beneath, 
it is necessary to dilute it with water until the smarting and 
burning otherwise produced is reduced to the point of 



DISEASES OF THE PHARYNX. 345 

toleration. But, the stronger it can be borne, the better the 
results. 

Dioxide of hydrogen (peroxide, H 2 2 ) nas Proven very 
effective when it could be used in full strength with an atomizer. 
I have used large quantities of it during the past few years with 
great satisfaction. It is one of the best of disinfectants and 
antiseptics. When a spray of the fifteen-volume strength is 
made to copiously cover the false membrane it immediately 
begins to foam. As it comes in contact with pus-corpuscles 
they are decomposed and oxygen is liberated to destroy the 
micro-organisms present. The mechanical effect of the process 
of effervescence appears to make the false membrane more 
friable, to loosen it, and to aid in its removal. It is best to 
spray an abundance of the fresh preparation into the throat 
while the tongue is depressed, so as to reach every part of the 
pharynx. Then the patient, if old enough, is directed to hold 
it in the throat and gargle it so that contact is prolonged. Gag- 
ging should be avoided for fear of producing vomiting and the 
loss of much-needed food. The tongue-depressor must not be 
carried far enough back on the base of the tongue to cause 
retching. This treatment has proven very effective in my 
experience, and is repeated every half-hour, or every one, two, 
or four hours, as the conditions demand. Pynchon adds 1 grain 
of mercuric bichloride to 4 ounces of the dioxide to increase its 
germicidal action. It is of prime importance that the hydrogen 
dioxide be strictly pure, fresh, and just opened, and not allowed 
to be exposed to the air, heat, or light. If the pure dioxide 
cause too much smarting, it can be diluted. 

For some years before sulphocalcin and dioxide of hydro- 
gen were introduced I used lactic acid in a steam-atomizer. It 
appeared to have a beneficial action in softening and loosening- 
the false membrane. It is a favorite remedy with Lennox 
Browne, who applies it pure once or twice a day and has the 
nurse make applications of a dilution, 1 to 6, every two or 
three hours. It is to be pressed into the false membrane with 
a cotton swab. This cotton-applicator should always be used 
instead of a brush, for the latter is sometimes laid aside and 



346 DISEASES OF THE EAR, NOSE, AND THROAT. 

forgotten only to be used at some future time and add more 
sorrow and deaths to the account of diphtheria. Such instances 
are on record. When pieces of the diphtheric membrane are 
macerated in pure lactic acid outside the body it becomes "-soft, 
translucent, and jelly-like." 

There is one objection to all applications that must be 
made with swab, brush, probang, etc. In the case of fighting, 
struggling children they probably do more harm than good by 
exhausting the little patient's strength. 

I have used the purple, or blue, pyoktanin, but am not 
satisfied of its value. From my experience with a 10-per-cent. 
solution of carbolic acid in glycerin in other diseases I am led 
to believe that its germicidal and local-aneesthetic effects would 
be valuable here. Lime-water irrigations and sprays have but 
little effect on the false membrane, but the direct fumes of 
slaking lime are beneficial, as even steam alone tends to soften 
and loosen the membrane. The lime-water makes the mem- 
brane more friable, but not thinner. I could never see any 
satisfactory results from potassium chlorate except simply as a 
cleansing solution. Salicylic acid is highly recommended by 
some Europeans, but is not in favor with Americans as a local 
remedy. I have no experience with it in diphtheria, but the 
results of trials with it for similar purposes in other diseases are 
not re-assuring. Insufflations of powdered sulphur are much 
used by the laity, but I have seen no benefit, though much 
misery, from them. 

Tearing off the pseudomembrane and cauterizing the mu- 
cous membrane is to be deprecated. Its forcible removal is 
justifiable only when it amounts to an actual obstruction to 
respiration. It should be borne in mind that the bacilli are 
not in the layer next the mucous membrane, but in the super- 
ficial layers. Generally they are not found to have penetrated 
to the mucous membrane, — a fact that seems to have been lost 
sight of by those physicians who aim to penetrate the deeper 
layer of the false membrane in order to inject remedies into the 
mucous tissues beneath, which opens up an avenue for the 
penetration of germs to the blood- and lymphatic vessels. 






DISEASES OF THE PHARYNX. 347 

J. Lewis Smith reports excellent results from the following 
prescription for topical application : — 

R Acidi carbolici, gtt. x. 

Liq. ferri subsulpliatis, fSiij- 

Glycerin! . . . fgj. 

Aquae purae, f 3ij. 

Loffler (Deatsch. med. Woch., October 18, 1894) gave to 
the Budapest Congress his formula for toluol for the local treat- 
ment of diphtheria. It consists of alcohol, turpentine, and 2- 
per-cent. phenol (proportions not given). Since then he has 
used the following formula : Alcohol, 60 volumes ; toluol, 36 ; 
liq. ferri chloridi, 4. In 71 cases in private practice he had no 
deaths; adding 30 cases in hospital with 5 deaths, makes a 
mortality of 4.9 per cent. 

The local applications of toluol " should be begun early, 
should be thorough, and should be repeated every three or four 
hours until the temperature sinks to normal, which usually 
occurs in from twenty-four to forty-eight hours. Afterward 
three times daily and continued as long as any membrane is 
present." 

Loffler claims that if this application is used often enough 
and thoroughly the disease does not spread and has not invaded 
the nose or larynx in any case so treated. Intense pain followed 
the application, so " 20 volumes of menthol were added, making: 
menthol, 20 volumes ; toluol, 36 ; absolute alcohol, 60 ; liq. ferri 
chloridi, 4." 

When the nose is invaded, a spray of dioxide of hydrogen, 
1 part in 5 or 10, if it smarts, or Seiler's alkaline antiseptic 
solution, the formula for which is given in Chapter XVIII, 
should be sprayed into the nose until it is cleansed. Then the 
nares are cleared by blowing or by cotton on the small carrier 
(Fig. 9), and aristol is insufflated by means of the small powder- 
blower (Fig. 32). 

Cold applied continuously to the throat with ice-bags (Fig. 
78) retards and modifies the intensity of the inflammatory action 
of the first stage, but, after the false membrane begins sepa- 
rating, continuous heat is indicated. The hot applications may 



348 DISEASES OF THE EAR, NOSE, AND THROAT. 

be better borne than ice in the first stage, and if cold appear to 
produce discomfort and irritation the heat should be substituted. 
Water as hot as can be comfortably borne may be used in the 
same rubber bags. 

Acids retard the proliferation of micro-organisms, and for 
that reason lemon-water and cold water acidulated with the acid 
phosphate or dilute sulphuric acid are of service and grateful to 
the patient. If the sulphuric acid is used it must be taken 
through a glass tube and must not be allowed to come in con- 
tact with the teeth on account of its deleterious action on the 
enamel. Frozen milk and beef-tea cool the throat, quench the 
thirst, and support the strength. Barley- and rice- water are to 
be recommended in the same way and for the same reasons. 

Internal Treatment. — The patient should be persuaded to 
take milk in preference to water for quenching the thirst and 
for the sake of maintaining the strength. Insistence may need 
to be resorted to for the sufferer's good. When the strength 
begins to wane alcoholic stimulants are necessary to bridge over 
the period of exhaustion and consequent collapse. Whisky, 
sherry-wine, or diluted alcohol in emergencies are mostly to be 
preferred. Stimulation and alimentation by enemata may be 
required when swallowing is impossible or the stomach rejects 
everything. Preparations of predigested foods, peptonized meat, 
etc., can be injected into the bowel per rectum through a large 
catheter extending well up toward the sigmoid flexure. 

Tonics are indispensable in severe cases. Quinine and iron 
are the favorites of most physicians unless heart-failure is im- 
pending, when strychnine is employed. Tincture of the chlo- 
ride of iron is given in large doses every two hours, proportioned 
to the patient's age. It is best combined with glycerin, as, for 
example, in Billington's formula : ty, Tincturas ferri chloridi, 
f3j ; glycerini, aquas, aa fgj. Mercury in the form of the bi- 
chloride and the mild chloride has for a long time been in high 
repute with the profession both in Europe and America. The 
corrosive sublimate is used in solution — 1 to 10,000 — locally, 
and considerable doses in the form of pills, etc., are also given 
internally. The calomel is administered internally and by 



" 



DISEASES OF THE PHARYNX. 349 

sublimation. Internally it is given in doses of i to 3 grains 
every two hours until the bowels move freely, and then the doses 
are placed at sufficient intervals to not weaken the patient by 
catharsis. When the membrane is discharged, the calomel is 
discontinued. I. N. Love uses sodium benzoate in doses of 5 
to 15 grains. Guttmann and others claim good results from 
pilocarpine, but its depressant action on the heart and the bron- 
chorrhcea it produces render its efficacy at least questionable in 
a disease with a natural tendency to heart-failure and respiratory 
obstruction. In case of enfeebled heart-action full doses of 
strychnia are indicated. Treatment for laryngeal invasion will 
be found in the division on the larynx. 

Apartments occupied by diphtheric patients must always 
be thoroughly fumigated with sulphur as soon as recovery 
takes place. Dry fumigation is not sufficient. In order to 
effectually destroy disease germs the air must be kept moist 
during the process of fumigation. 

Paralysis of the larynx, pharynx, velum palati, and lower 
extremities and loss of the tendon reflexes are sequels of diph- 
theria. Strychnine in large doses, especially subcutaneously 
injected ; central galvanization ; and local faradization have given 
the best results in overcoming these paralyses. 

The antitoxin, or blood-serum, therapy, already mentioned, 
is considered in the following chapter. 

Intubation is treated of under a separate heading. 




CHAPTER XXXI. 

DISEASES OP THE PHARYNX, CONTINUED. 

Diphtheria, Continued, 
serum therapy in diphtheria. 

Behring, Kitasato, Roux, Ehrlich, Martin, and others have 
found, as a result of their experiments, that if the blood-serum 
of animals that have been deprived of susceptibility to a disease 
be injected into other animals, it deprives the latter, in turn, of 
susceptibility to that disease, and modifies or aborts the disease 
if it is already present. Rabbits and guinea-pigs are employed 
in these experiments. If the serum from one of these animals 
previously immunified against diphtheria or tetanus be injected 
into another susceptible one, the latter is protected from the 
given disease for a time. 

The method of procedure in these experiments is, briefly, 
as follows : Enough of the poisonous product of the disease is 
injected into an animal to sicken it, but not to cause death. 
Small hypodermatic injections of diphtheria cultures and toxins 
are given at first and gradually they are increased as the toler- 
ance of the animal increases. As this process proceeds the 
blood of the injected animal acquires gradually increasing im- 
munifying powers. The injections are followed by local tume- 
faction and fever. At intervals a quantity of blood is taken for 
the purpose of experimental tests on other animals to determine 
its efficacy. After the latter is shown to be sufficient, a large 
amount of blood is taken from the animal, placed in vessels on 
ice to produce coagulation, and the separated serum, mixed 
with i of 1 per cent, of carbolic acid, constitutes the serum 
remedy. On account of their susceptibility and size, goats and 
horses are employed to obtain this serum in large quantities. 
An enormous amount of this is produced in Germany. Behring 
says : " The works can now supply one hundred thousand doses 
(350) 



DISEASES OF THE PHARYNX. 351 

a month, which barely keeps pace with the demand from Europe 
and America." 

The benefit to be derived from the antitoxin injection de- 
pends largely upon the time in the history of the disease at 
which the remedy is employed. If three or four days or a 
longer time has elapsed, so that the disease has invaded the 
larynx or bronchial tubes, and the profound toxic effects of the 
diphtheric poison are manifested in the heart, nothing may save. 
If the building is nearly consumed by fire, water cannot save it. 
However, the patient should always be given the benefit of a 
doubt and the remedy that promises the most hope must be 
used. 

The German physicians report a large saving of life by the 
use of the serum therapy. Roux, of Paris, claims similar results. 
It is asserted that the serum itself is harmless, and some deaths 
that have followed immediately upon the injections may have 
been due to other causes, such as the syringe penetrating a vein 
and injecting air, or heart-failure, etc. Other deaths may have 
been caused by the accidental introduction of some other ma- 
terial of a septic nature. The varying results apparent in the 
statistics of different observers and hospitals are likely affected 
to a considerable extent by a difference in the virulence of the 
several epidemics and of different cases in the same epidemic. 

In reviewing the subject of blood-serum therapy, or anti- 
toxin treatment, with a view to fix its present status and to 
place a just and impartial estimate upon its actual value in 
diphtheria, I have investigated the current literature on the 
question down to the present time. I shall offer the evidence 
on both sides, and the reader would best assume a judicial atti- 
tude and decide according to the law and the evidence as they 
are presented by the several able advocates. 

The serum injections are made in the loose subcutaneous 
tissue, generally below the axilla or between the shoulder-blades, 
after preparing the skin by washing with soap and a bichloride 
solution, 1 to 1000. The antitoxin of Behring comes in her- 
metically-sealed flasks or vials bearing labels that indicate the 
doses contained. Each vial contains one dose, as follows: No. 1, 



352 DISEASES OF THE EAR, NOSE, AND THROAT. 

600 immunizing units, to be used on the first or second day oi 
the attack ; Xo. 2, 1000 units, for serious cases on first or second 
day or in mild cases of longer duration ; Xo. 3, 1500 units, for 
adults or severe cases in children. If one injection does not 
prove effective, it is repeated after twenty-four hours. 

As a prophylactic, smaller doses are given. For children, 
100 to 200 units are sufficient. The length of time this dose 
affords immunity is not definitely known, but it is safest not to 
allow more than three weeks to elapse with a child still exposed 
to the disease without a repetition of the protective dose. An 
extended treatment of this subject may be found in an excellent 
monograph entitled " Blood-serum Therapy and Antitoxins," by 
G. E. Krieger, Chicago. 

We will now consider the results of the blood-serum 
therapy. 

Behring (Deutsch. med. WocJi., January 10, 1895) an- 
nounces that the dose of 60 units, at first considered sufficient, 
is too small for some cases, and that 150 units had better be 
given in all cases. Even this dose is not always sufficient when 
the infection is virulent and the period of incubation nearly 
over. In such cases a full dose of Xo. 1 (600 units) may not be 
sufficient to prevent the development of the disease. An attack 
following the injection is usually mild. In 10,000 cases immu- 
nized only 10 contracted diphtheria. The antitoxin is excreted 
by the kidneys, and immunity depending on it ceases when all 
is eliminated. The larger the total dose, the longer the immu- 
nity, and smaller doses at intervals are more serviceable than 
one large dose. 

For the first time Professor Behring has replied to the 
critics of antitoxin, and supports the efficacy of this discovery 
by innumerable statistics (Deutsch. med. Wbch., 1895, Xo. 38). 
He claims that even statistics do not do it justice, as it is used in 
perhaps the more desperate cases, and the mortality percentage 
is, therefore, higher than it should be in proportion. But, even 
allowing for countless errors, the percentage is a great gain over 
the past. The mortality in Berlin in 1895 sank to 15 per cent., 
two-thirds less than it had averaged during the seventeen vears 



DISEASES OF THE PHARYNX. 353 

preceding, while the character of the diphtheria was more seri- 
ous than at any time since 1886. Of 10,312 cases, 5833 were 
treated with serum, with a loss of 9.6 per cent., while 3479 
cases treated without it showed a mortality of 14.7 per cent. 
The percentage fell to 10.3 per cent, in the Contagious Disease 
Institute, where the serum was exclusively used. 

He asserts that the question now is : Shall it be used to 
secure immunity ] For this purpose he recommends one-half 
of a regular dose. Improved methods have enabled the dose 
to be concentrated from o cubic centimetres into 1 cubic centi- 
metre. He regrets that the specific for tuberculosis is not yet 
all that was hoped for it, but congratulates Ransom on his 
cholera serum and Knorr on his for tetanus. (Centralblatt filr 
Chirurgie, January 11.) 

" Professor Behring delivered a recent address on this sub- 
ject in which he replied to the swarms of critics who have been 
attacking him the past year or so. He maintained that sta- 
tistics prove the efficacy of the serum, and that the 60,000 
deaths from diphtheria which the German empire has averaged 
each year will be found to be reduced to 40,000, and a more 
general use of the serum would reduce this to one-third. 
Throughout the city of Berlin the fatality in diphtheria amounted 
to 30 per cent., but in the Contagious Hospital, where serum 
was promptly used, the mortality was only 20 per cent. In the 
same time in 1895 it was only 10.3 per cent. The mortality in 
the hospitals had always been much greater than outside here- 
tofore. Last year the percentage of mortality in diphtheria 
cases in Berlin fell to 15 per cent. During this period the dis- 
ease was not a mild form, but averaged more morbid symptoms 
than at any time since 1886. During the first three months of 
1894, when the serum was not to be had, there were 363 deaths 
per 1000, while the last three months, when everybody could 
get the serum, there were 198 deaths per 1000." {Journal of 
the American Medical Association, February 8, 1896.) 

" Kossel, speaking for Koch and of the results obtained in 
the Institute for Infectious Diseases at Berlin, declares that no 
uncomplicated case that was treated in the first or second stage 

23 



354 DISEASES OF THE EAR, NOSE, AND THROAT. 

of the disease was lost, and that the mortality of all cases was 
reduced to 16 per cent." (Sajous' "Annual of the Universal 
Medical Sciences.") 

Kossel (Deatsch. med. Woch., October 25, 1894) with cow- 
serum reports 117 cases of diphtheria with 13 deaths, or 11.1 
per cent. Kossel concludes " that one cannot expect to cure 
every case of diphtheria with serum, but that with a sufficient 
dose recovery will follow with certainty in all cases of fresh, un- 
complicated diphtheria. The prognosis is also much better, 
even in the later stages of the disease, than without the serum 
treatment." 

The use of antitoxin is highly extolled by the French. M. 
Monod claims that its use has decreased the mortality from 
diphtheria 6b per cent., and it is claimed that by its use 15,000 
lives in France have been saved. 

"In the Hopital Trousseau (Med. Press, January 9, 1895), 
during October and November, 1894, 302 children were ad- 
mitted to the ' doubtful wards,' and were at once injected with 
20 cubic centimetres of serum. Later, 53 were recognized as 
not diphtheria, and remained in these wards until recovery, none 
contracting diphtheria. Two hundred and forty-nine children 
were admitted to the diphtheria wards, and at the expiration of 
Moisard's term 18 were still under treatment. Of the remain- 
ing 231, 34 died, or a mortality of 14.7 per cent. As sequels 
of the serum therapy there were, in all, 14 cases of urticaria, 9 
of scarlatiniform erythema, 9 of polymorphous erythema, and 1 
of purpura." 

"In. the Hopital des Enfants Malades, Paris, there was a 
reduction of mortality by serum therapy in 448 cases to 24.33 
percent, as against 51.71 per cent, for 3971 cases occurring 
from 1890 to 1894. In no case was there any untoward result 
that could be ascribed to the treatment except slight urticaria. 
The beneficial effects of the serum were a marked improvement 
in the general condition ; a cessation of the growth of membrane 
within twenty-four hours, and disappearance of the membrane 
after thirty-six to seventy-two hours, with rarely a longer per- 
sistence ; a return of the temperature to normal ; a diminution 



DISEASES OF THE PHARYNX. 355 

of the amount and frequency of albuminuria ; and the appear- 
ance, less often, of such diphtheric sequelae as paralyses," etc. 
(American Year-book, 1896.) 

" Kitasato, of Tokio, has collected from reliable sources 
26,521 cases of diphtheria in Japan previous to serotherapy, 
with 14,996 deaths (56 per cent.) ; while of 353 cases treated 
here from November, 1894, to November 25, 1895, there were 
only 31 deaths (8.78 per cent.). There is reason to believe 
that the mortality can be lowered if the treatment could be 
commenced early in the course of the disease. Thus, in 110 
cases in which injections were made within forty-eight hours 
after the invasion all ended in recovery. On the other hand, 
of 33 cases treated after the eighth day of the disease 11 were 
lost. Some of the patients were brought into the institute in a 
moribund condition ; 6 children died within five hours after ad- 
mission; 6 more within ten hours; altogether 21 cases (two- 
thirds of the total mortality) were lost within the first twenty- 
four hours. As to the effects of the serum on the course of the 
disease, the points to be noted are: 1. The fall of temperature; 
in many places the defervescence was almost critical, and it takes 
place usually at the end of twenty-four to forty-eight hours. 
2. The separation of the false membrane, which takes place, as 
a rule, after the return of the temperature toward the normal. 
Very large casts of the trachea and larger bronchi have been 
coughed up. 3. Urticaria-like eruptions were observed in very 
many cases, being, in some, quite severe and annoying. They, 
however, disappeared in a few days without any treatment. 4. 
In 4 cases marked albuminuria was observed at the time of 
admission. In these cases albumin disappeared from the urine 
in the course of the treatment. Pyrexia was accompanied by 
albumin in the urine, but there was no reason to believe that 
any renal trouble was caused by the injections. 5. Five cases 
developed paresis of the soft palate. Microscopic as well as 
culture examinations were made in every case, and Dr. Kita- 
sato's report only deals with those cases in which Loffler's 
bacilli were demonstrated to be present." {Journal of the 
American Medical Association, May 9, 1896.) 



356 DISEASES OF THE EAR, NOSE, AND THROAT. 

H. Gradle writes as follows, January 26, 1896 : " Of a 
total of 3311 cases collected by Behring from the health reports 
in Berlin, in 1895, since the general use of antitoxin, 16 per 
cent, died, while according to previous experiences in the same 
places and by the same observers the mortality had been from 
31 to 36 per cent. The death-rate is not the same in different 
cities and among different classes of the population, but, what- 
ever it has previously been, it was always diminished by the new 
treatment. There is not a single record of any observer who 
has seen a sufficient number of patients to draw statistical 
inferences but what confirms the life-saving effects of the anti- 
toxin treatment. No such evidence has ever been brought 
forward to prove the efficacy of any other treatment in diph- 
theria, and those physicians who speak boastfully of their time- 
honored remedies in their own hands cannot adduce the testi- 
mony of others in favor of their pet medicines, as no two 
text-books formerly agreed on the treatment of diphtheria. 

" Does the use of antitoxin involve any danger % A few 
deaths have been reported as occurring soon after the use of the 
remedy. But no observer who is familiar with the treacherous 
nature of the disease and the sudden heart-failure which some- 
times occurs even in the mildest forms of the diphtheria can 
be convinced that antitoxin is responsible for these deaths. It 
was simply used too late to prevent them. An unpleasantness, 
but not a real danger, which has, however, been observed in 
about 5 per cent, of the cases treated, is a slight feverish disturb- 
ance, sometimes with pains in the joints or a rash on the skin. 
This incident, which has never proved serious, is insignificant in 
proportion to the positive danger of the disease which the 
treatment reduces. 

" The prevention of diphtheria by means of antitoxin given 
after exposure to the disease, but before it has broken out, has 
likewise proved an unqualified success. Observations in chil- 
dren's hospitals and orphan-asylums, particularly in New York 
City, have shown this. Epidemics which in former times could 
be checked in such institutions with difficulty, and only by per- 
sistent quarantine of all the inmates, have been stopped promptly 



,tly 



DISEASES OF THE PHARYNX. 357 

within the last year by the preventive use of antitoxin. The 
experiences of the physicians acting for the Chicago Board of 
Health have also confirmed the utility of the preventive treat- 
ment in checking the spread of the disease in crowded tenement- 
houses." (They confirm these reports at the present time, 
January, 1897.) 

Karlinski (Wien. med. Woch., February 16, 1895), as a 
result of a careful series of experiments on his own person, 
concludes that the diphtheric-heilserum influences in no way 
the metabolism of a healthy organism, and that the albuminuria 
in diphtheric cases treated with antitoxin should be ascribed to 
the disease rather than to the remedy." 

Foster {Medical News, February 2, 1895) says: "Of 2740 
cases, including those requiring tracheotomy and intubation, 
treated with antitoxin, 509 died, — 18.51 per cent. Of 4445 
cases not treated with antitoxin 2017 died, — -15.36 per cent. 
All the cases recovered when the antitoxin was injected on the 
first day of the disease ; 2.83 per cent, died when the injections 
were begun on the second day ; 9.99 per cent, when the first 
treatment was on the third day ; 20 per cent, died when the 
first treatment was on the fourth day ; 33.33 per cent, when the 
injections were begun on the fifth day; 841, or 38 per cent., 
when they were begun after the fifth day." 

Edwin Rosenthal (Transactions of the Philadelphia County 
Medical Society, January, 1896) says: " The antitoxin serum is 
used as a curative or immunizing agent by subcutaneous injec- 
tion into the tissues of the body. The parts chosen w r ere in the 
back between the scapulae, on either side of the vertebral 
column, though other parts of the body, as the loins, groins, or 
the side of the chest, have been selected. 

" The parts were cleansed with alcohol soaked on sub- 
limate cotton or gauze, the injection was made at one time 
with a suitable syringe, and after injection the parts were soaked 
with iodoform collodion. 

" The quantity injected depended upon the severity of the 
case and the day of the disease when the injection was made. 
If in the first two days and the disease mild, 600 units were 



358 DISEASES OF THE EAR, NOSE, AND THROAT. 

injected. If, however, the case were more severe, as in the 
laryngeal variety, or after two days, 1000 or 1500 units were 
injected. These injections were repeated, if necessary, in twelve 
to twenty-four hours. After injection, if the pulse and temper- 
ature declined, no more antitoxin was given ; but, if the symp- 
toms continued or became more urgent, larger quantities of 
the serum were injected until the characteristic decline took 
place." 

Rosenthal chose his dosage in units for the reason that so 
many different antitoxins were sold. He had used Behring's, 
Aronson's, Gibier's, Roux's, Solis-Cohen's, and Mulford's, and 
each variety represented a different strength, 1 cubic centimetre 
(about 15 drops) representing 60, 100, or 150 units ; it was, 
therefore, easy to use the required dosage if the strength of the 
antitoxin were known. For instance, an injection of 1000 units 
of Mulford's antitoxin would require 10 cubic centimetres at a 
dose, and so on. A total of 222 cases with 13 deaths showed a 
mortality of 5J-g- per cent. Of the 84 laryngeal cases, 12 died; 
31 were intubated, with 5 deaths. 

Rosenthal's conclusions were : " Antitoxin is a specific in 
diphtheria; but, while acting specifically, it is not a cure-all, 
and other treatment must be pursued as indicated by the special 
case. The earlier the antitoxin was used, the more certain was 
its success." 

R. H. Babcock, in the President's Address before the Tri- 
State Medical Society, in Chicago, April 7, 1896, spoke as fol- 
lows : " The crowning achievement in this line of work has 
come through the chemistry of bacteriology. Nuttall conclu- 
sively demonstrated in 1888 the power possessed by the blood- 
serum of combating the poisonous products of bacterial growth, 
but to Behring and Kitasato, in 1891, belonged the credit of 
having found a practical means of utilizing antitoxins in the 
treatment of disease." To those who decry the -antitoxin treat- 
ment of diphtheria as dangerous and its advantages as not yet 
proven, Babcock commended the criticism by Welch in the 
Johns Hophins Bulletin of October, 1895. Welch's analysis of 
cases treated and published up to that time, in the opinion of 



DISEASES OF THE PHARYNX. 359 

Babcock, " sets at rest all doubt concerning the great reduc- 
tion in mortality accomplished by this treatment, and renders 
the physician culpable who refuses this remedy to his patients." 

Rosa Engelmann, of the Chicago Health Department, in 
detailing the results of her experience with antitoxin says : 
" Seven deaths in 103 cases, or 6.97 per cent., is a very low 
death-rate, especially if one consider that 50 of the 103 cases, 
or almost 50 per cent., were croup, — the most dangerous form 
of diphtheria. Doubling this death-rate to 14 per cent, for the 
laryngeal cases still leaves a remarkably low mortality. This 
brilliant record is due to the fact that 91 of the 103 cases were 
injected within the first three days." {Medical Standard, 
March, 1896.) 

Hare (Therapeutic Gazette, January 15, 1895) indorses 
serum therapy, but emphasizes the necessity of not omitting 
other treatment. " Three tilings are important to know when 
using antitoxin : 1. That a single dose of antitoxin is not always 
sufficient to counteract the poisonous infection. 2. While it 
may counteract the results of the Loffler bacilli, it does not pre- 
vent its continued growth at the site of infection, — throat, nose, 
etc., — and the patient may still be dangerous to infect others 
even after all the usual traces have disappeared. 3. It does not 
combat other infection, as the streptococcus or the like ; it may 
prevent it if used early enough ; but other treatment must be 
used in conjunction to make a favorable result." (Charlotte 
Medical Journal, February, 1896.) 

The majority of the members of the American Pediatric 
Society, at its meeting in May, 1896, were of the opinion that 
the effects of the serum therapy in diphtheria justified an ex- 
tensive trial. The same opinion prevailed in the Association of 
American Physicians. 

John Winters Brannon, physician to the Willard Parker 
Hospital, New York (International Medical Magazine, January, 
1896), says: "I must admit that I am as yet unable to range 
myself either among the enthusiastic advocates of diphtheria 
antitoxin or with those who unqualifiedly condemn it. Perhaps, 
if I touch upon some of the clinical features of diphtheria as 



360 DISEASES OF THE EAR, NOSE, AND THROAT. 

modified by the administration of antitoxin in the Willard 
Parker Hospital, the reasons for my position may become 
apparent. 

Ci Among the favorable results claimed to follow upon the 
injection of antitoxic serum are a prompt improvement in the 
general condition of the patient, a strengthening of the action 
of the heart, a fall of the temperature, a rapid disappearance or 
4 melting away' of the membrane in the throat, and marked re- 
lief of laryngeal stenosis. I have already said that I believed 
that antitoxin often had a favorable effect upon the laryngeal 
symptoms, and I am inclined to think that this is especially 
true of the intubated cases, which seem to do better under anti- 
toxin than without it. On the other hand, I have failed to note 
any effect, favorable or otherwise, upon either the pulse or the 
temperature, nor have I ever seen any 'melting away' of the 
membrane which is not also observed in cases which have not 
received antitoxin. There is a case now in the wards in which 
the membrane has persisted for three weeks, although antitoxin 
was given on the third day of the disease. The general con- 
dition has also usually remained unaffected, except as it might 
be influenced by the relief of laryngeal stenosis referred to 
above. 

" Now as to the alleged untoward effects of antitoxin. It 
has been said to cause nephritis, or, at least, albuminuria, and 
to favor post-diphtheric paralysis, or dissolve the red cells of the 
blood, and to set up septicaemia in some manner as yet unex- 
plained. In regard to all these clinical phenomena, I can only 
say that I have failed to observe them, though I have looked 
for them day by day, particularly during the past eight months. 
Cases have shown albuminuria as in previous years, and, in the 
opinion of one of the resident staff, rather more than formerly, 
but casts or other evidence of nephritis have been absent. 
Suppression of the urine occurs, but not with unusual frequency. 
With the exception of simple regurgitation due to temporary 
paresis of the palatal muscles, I should say that post-diphtheric 
paralysis has been noteworthy by its absence during the present 
year. With regard to the destruction of the red cells of the 



DISEASES OF THE PHARYNX. 361 

blood or the occurrence of septicaemia, I have seen nothing 
which would lead me to attribute either of these morbid proc- 
esses to the administration of antitoxin rather than to the diph- 
theric poison itself. Among the hundreds of cases treated this 
year in the hospital, there is but one in which, in my opinion, 
antitoxin may have contributed to the fatal termination. In 
the case in question, a severe one at the outset, a synovial in- 
flammation developed in several joints some ten days after the 
injection of serum, coincidently with an urticarial eruption cover- 
ing the legs and trunk. The fluid in the joints became puru- 
lent and the signs of broncho-pneumonia were found in the 
lungs. After a protracted illness the child died, and, on autopsy, 
in addition to the pus in the joints and the pulmonary consoli- 
dation, there was found marked fatty degeneration of the heart 
and kidneys. This case would probably have died from other 
complications, but we cannot but associate the joint process 
with the giving of antitoxin." 

In the Journal of the American Medical Association for 
February 9, 1895, B. Becker quotes as follows: " Koerte says: 
4 Bacteriologists say that antitoxin, if early used, will almost 
surely cure the genuine diphtheria. They wish those cases ex- 
cluded which are complicated by the presence of other bacteria 
or cocci. In regard to this, I must say that we, as practi- 
tioners, when we talk about cure and treatment of diphtheria, 
must keep in view the clinical symptoms and appearance of the 
disease, and that under this well-known and fully-characterized 
picture also those cases belong which are described as mixed 
infections. Every physician will declare such a case a severe 
one of diphtheria. From this point of view it is at this time 
not probable yet that antitoxin will cure all cases of diphtheria, 
in a broader sense. Also the assertion that in an early and 
sufficient use of the serum all cases of genuine diphtheria can 
be cured is not proved yet. There is the possibility that in 
various epidemics those cases of mixed infection are so frequent 
that they may make a limit for the use of the serum. In spite 
of the rather favorable results which I have related, a longer 
continued observation at the bedside only can bring a decision 



362 DISEASES OF THE EAR, NOSE, AND THROAT. 

as to the value of the antitoxin.' " {Berlin. Jclin. Wocliensclirift.) 

A discussion of the antitoxin was brought up at the Med- 
ical Association of Munich, after the hearing of reports of cases 
by Bucher, von Ranke, Seitz, and Emmerich. The following 
resolution was unanimously adopted by the association : — 

"1. To give a positive opinion about the value of Behring's 
serum is not possible at this time, especially on account of the 
differences of diphtheria in regard to appearance and severity 
of the disease ; only a longer and closer observation can have 
a positive effect. It must be recommended, therefore, not to 
expect an absolute panacea, which suggestion should be given 
to the public also. 

" 2. Our experiences with the antitoxin are of such a kind 
that we consider it worthy of further investigations and trials, 
especially in clinical and polyclinical institutions, as those places 
are the most fit for such experiments." {Munchener medic. 
Wocliensclirift. ) 

The opposition to the serum therapy finds an advocate in 
Lennox Browne ("Diphtheria and its Associates," 1895), who 
claims as a result of his experience with the antitoxin " A 
greater number of children have been found liable to attacks of 
cyanosis and fainting, with a correspondingly-increased demand 
for nervines and stimulants. Complete recovery is, for the most 
part, delayed, and an unexpected fatal result at a late period is 
more frequent. When drawing attention at a meeting of the 
Clinical Society, last December, to an increased liability to the 
most grave complications of diphtheria — viz., anuria, nephritis, 
and cardiac failure — under the use of serum we took occasion to 
express a hope that further experience might prove that the dis- 
advantages of serum would be more than outweighed by its 
benefits." In 1000 cases with 284 deaths as compared with the 
earlier methods of treatment, he says : " The actual mortality 
was the same, — namely, 27. It was 27.10 on the whole number 
— 1163 — treated during the year 1894 at the hospital whence 
our comparisons were made." 

" The foregoing observations as to the effects of serum 
treatment will, we trust, have made it clear that the injection of 



DISEASES OF THE PHARYNX. 363 

antitoxic serum into a patient attacked by diphtheria is not 
altogether free from an added danger, notwithstanding that the 
amount of active principle administered can be measured only 
by million ths ; and we have seen that the power of this serum 
to do good and, per contra, its capacity for inflicting injury is in 
proportion to the duration of the disease, — in other words, to the 
degree of the toxaemia. 

" As a corollary, we might be able to pronounce that the 
power of antitoxic serum to act as a prophylactic against a pos- 
sible attack of diphtheria is in proportion to the rigor and 
healthy blood condition of the individual in whom it is em- 
ployed ; but the very minute dose administered for this purpose 
is evidently capable of being soon broken up by cellular action 
in the healthy. 

" We can, therefore, understand the general admission as 
to the evanescent character of the immunity so obtained. 
Moreover, reports of cases are not wanting in which noxious 
and even fatal results have followed the use of serum when 
employed as a prophylactic. 

" On all these grounds, therefore, we do not feel justified 
in recommending serum for this purpose. More real methods 
of preventing the spread of diphtheria are to be found in im- 
proved sanitation, in prophylactic surgical treatment already 
detailed, and in efficient isolation and disinfection." 

Kassowitz (Wien. med. WocJi., Xos. 5 to 8, 1895) opposes 
serum therapy for the reasons that ' ; Attempted immunization 
toward diphtheria has failed repeatedly ; relapses have occurred 
in children treated in the first attack with antitoxin ; injection 
on the first or second day has not always averted a fatal issue, 
death in some cases occurring as a result of the diphtheric toxin ; 
post-diphtheric sequels seem as frequent as formerly ; the anti- 
toxin has no sudden antipyretic action ; the membrane does 
not seem to be loosened earlier or its formation checked ; 
and the total mortality for diphtheria in Berlin has not been 
lowered. " 

Hagenbach ( CorrespMatt fur Schweizer Aer., January 1, 
1895) used Behring's heilserum in a severe case of diphtheria 



364 DISEASES OF THE EAR, NOSE, AND THROAT. 

with the following results : " Three days after the injection 
petechias broke out on the neck and spread over the whole body, 
vomiting- set in on the seventh day, and death occurred on the 
tenth. The autopsy showed hsemorrhagic gastro-enteritis, a 
high degree of fatty degeneration of the heart, and parenchyma- 
tous nephritis." 

Winters {Medical Record, April 20, 1895) opposes the 
serum treatment, declaring that, during an experience of three 
months in the Willard Parker Hospital with one hundred and 
fifty-four cases treated by it, " In not a single case has there 
been the least evidence that the formation of the pseudomem- 
brane was checked, that the exfoliation of the pseudomembrane 
was hastened, or that the throat was free from the membrane 
earlier than in the cases that have not been treated by antitoxin. 
In not a single septic case has the antitoxin made the least 
impression on the symptoms. The toxeemia has not in one 
instance been relieved or lessened. There has been no indi- 
cation, in the character or frequency of the pulse or in the 
general condition of the patient, that a specific for the toxaemia 
had been administered. The antitoxin is, therefore, opposed, 
first, because it does not neutralize the toxaemia nor favorably 
influence any of the clinical manifestations of diphtheria, and, 
second, on account of its immediate danger to life through its 
influence on the kidneys and on the nervous system, and, re- 
motely, through its influence on the blood." 

Strueh (Journal of the American Medical Association, May 
16, 1896) opposes antitoxin therapy and cites the unreliable 
character of statistical information, instancing the variations in 
mortality in the Children's Hospital at Basel. In 1876 the 
death-rate was 34 per cent.; in 1886 it was only 6 per cent. 
" Had they used any new remedy during the latter year the 
decrease in the mortality would undoubtedly have been ascribed 
to the new treatment." 

Ewing finds that " the antitoxin caused a diminution of 
the red blood-corpuscles and extensive changes in the leuco- 
cytes. These changes are likely to lead to obstructions in the 
capillary circulation, to changes in the kidneys, to necrotic foci 



DISEASES OF THE PHARYNX. 365 

in the liver, to pneumonia areas in the lungs, to obstructions of 
the cerebral circulation, and possibly to convulsions." 

Several deaths have been directly attributed to antitoxin 
injections. One reported recently well illustrates these deplor- 
able experiences. James L. Taylor writes to the Journal of the 
American Medical Association as follows (April 4, 1896): "A 
most unfortunate and distressing accident occurred in the practice 
of Dr. S. S. Halderman, of Portsmouth, Ohio, on March 22, in 
connection with the use of antitoxin. A mild form of diphtheria 
was prevailing in the family of Mr. George Kricker, cashier of 
the Central Savings-Bank, and the doctor administered the usual 
dose of antitoxin, as a prophylactic, to a little boy, 5 years old, 
in whom the disease had not yet appeared. The child, which 
had seemed to be in perfect health up to this time, was asleep 
when the injection was given, and in five minutes was a corpse. 
The doctor had withdrawn to another room to refill his syringe 
for use on another child when the mother noticed the boy's lips 
puffing up, and called to him that something was wrong with 
Willie. By the time the doctor reached the child, breathing 
had ceased. The killing fluid, which thus acted with far more 
rapidity than a fatal dose of morphia, arsenic, or strychnia given 
per mouth would have done, seems to have caused death by 
paralyzing the heart. At least, that is the cause assigned in the 
death-certificate. The serum was Behring's fresh, injected 
beneath the scapula and in the usual way. The doctor, one of 
the first to introduce antitoxin into medical practice in Ports- 
mouth, was an enthusiastic advocate of serum therapy, and 
presumably used all the precautions which skill and experience 
can suggest. This terrible accident, therefore, can have but one 
meaning. It furnishes absolute proof of the inherent danger of 
antitoxin as a therapeutic agent." 

In a private letter of July 9, 1896, from Edwin Klebs, 
formerly of Germany, now Professor of Pathology in the 
Chicago Post-Graduate Medical School, he says : " The good 
effect (of serum therapy) in the first two days of diphtheria 
seems to be doubtless." Referring to the Atlanta meeting of 
the American Medical Association, he continues : " I remarked 



366 DISEASES OF THE EAR, NOSE, AND THROAT. 

the dangerous effects in some rare cases, as that of Professor 
Langerhans. Now. the papers bring the notice that the death 
occurred by the introduction of stomach-contents in the bronchi. 
I do not know if that is acceptable, possibly post-mortal. I 
wished to point out the problem to get the antitoxin substances 
in a purer form, so that all possibility of infection may be 
avoided." In his discussion at the meeting referred to, Pro- 
fessor Klebs said : " Now I come to a point that seems to me to 
be of the highest importance, — the danger of antitoxin. I wish 
that point would be illustrated in a more extensive manner by 
publishing all cases in which the injection was shortly followed 
by death. We have such cases, but a part of them seems to be 
on account of the disease. But if in one case alone the patient 
has been killed by antitoxin, we have a great interest to find 
out the true cause of the death. Such a case is that of Pro- 
fessor Langerhans, in Berlin. After a girl in the house became 
diphtheric, he thought he would, if possible, prevent the 
spreading of the disease to his own children, but after the 
injection the first child died immediately. So it is possible 
that death may occur after the most cautious injection of 
antitoxin, — a fact that gives a high responsibility to every 
physician using this remedy. We must search, therefore, to 
find out what may have been the cause of such fatal accident. 

" In this case it is reported that the body of the dead child 
was quite normal, well nourished. There was no introduction 
of air into the blood. The danger of introducing air is, by the 
way, not so great as often accepted. One can inject some centi- 
metres of air in the blood-vessels of a rabbit without any bad 
effect, as the air is resorbed in a very short time. It will be 
better to inject the fluid in children into the muscles far distant 
from the lungs, — the dorsal or gluteal region. Then it is con- 
venient to push the needle alone in first and see if bleeding fol- 
lows or not. If not, one may inject without fear, but always 
slowly, under no high pressure. If these precautions are fol- 
lowed, I think that no danger can be feared from the injection. 

" I think it is not probable that the antitoxic serum itself con- 
tains such a formidable heart-poison, as very great quantities of 






DISEASES OF THE PHARYNX. 367 

it injected into the peritoneal cavity of animals prove harmless 
Much more probable it seems to me, that in this and other simi- 
lar cases observed in Brooklyn, N. Y., an accidental pollution 
of the antitoxin has combined with intra-venous injection to 
produce the fatal effect. 

" The sure disinfection of serum is a very difficult matter. 
Twice I have found microbes in tubercle serum. On the other 
side, the best antiseptics — as mercury bichloride, phenol, and 
kresol — make coagulations in the serum. Therefore, one must 
search for other disinfectants that will not coagulate albumin- 
ous matters. I note that chinosol is proclaimed as such by 
Emmerich ; its antiseptic action is forty times stronger than 
carbolic acid and does not coagulate albumin. I have proved 
it a very good disinfectant for external and internal use, and I 
would recommend it for the disinfection of serum. Certainly 
we must demand from the manufacturers of antitoxic serum 
that they must prepare the serum in an absolutely-pure man- 
ner, excluding totally the possibility of accidental pollution. 
It is not a good manner to dispense it in colored bottles. It 
can be protected against the light by dark coverings. 

" I am sure that all these precautions can be executed and 
will be executed in this land, in which I have seen as good 
bacteriologic work as anywhere in Europe." 

In the case of the sudden death of Professor Langerhans' 
child, the official report says "that previous to the fatal injection 
the child had taken dinner, followed shortly afterward by some 
milk and cake. Death took place during a severe fit of cough- 
ing, and the necropsy showed that the trachea and bronchi were 
entirely filled with a gray substance, which was proved by micro- 
scopic examination to consist of particles of food, a good deal of 
the same being still present in the stomach. The uvula was swol- 
len. The medical experts declare, therefore, that the child died 
from suffocation. They are of the opinion that the boy vomited 
after the injection, and that, being in a fainting state from the pain 
of the injection, he was not able to get rid of the vomited matter, 
but drew it into the larynx in the act of inspiration. They did 
not find any embolus of air in the pulmonary artery, as was 



368 DISEASES OF THE EAR, NOSE, AND THROAT. 

suggested, nor was there any confirmation of the opinion that 
death had occurred by syncope. According to the statement of 
the Control Office, the serum was of normal quality." {Journal 
of the American Medical Association, July 11, 1896.) 

Reports of health commissioners of various cities give the 
results of the serum therapy as follow : In New York City the 
death-rate was reduced by antitoxin from an average of 33.93 to 
21.16 per cent.; Indianapolis, from 26.29 to 13.36 per cent.; 
St. Louis, in 1894, with no antitoxin the death-rate was 28.2 
per cent., and in 1895 the death-rate among those treated with 
antitoxin was 8.4 per cent. The Chicago Health Department 
reports (May, 1896) a reduction from 52 to 9 per cent. ; Boston, 
from 50 to 16. The Kaiser and Kaiserin Hospital, of Berlin, 
reports a reduction from 50 to 10 per cent., and the Willard 
Parker Hospital shows a mortality of only 10 per cent, under 
serum therapy (Neio York Medical Journal, February 15, 1896). 
In the Boston City Hospital the reduction in the death-rate was 
from 42 to 17 per cent. In the Johns Hopkins Hospital Bulle- 
tin W. H. Welch shows that, in 814 cases in which the serum 
was used before the third day, the percentage of deaths was 
only 5.5 per cent. 

Regarding the present status of medical opinion, an edi- 
torial in OaillarcVs Medical Journal for June, 1896, says : "The 
present status of the question undoubtedly justifies the early use 
in moderate quantities of a good preparation of antitoxin. We 
are not prepared to say the failure to use it under such con- 
ditions would be as easy to explain or to justify. The records 
of the last eighteen months have shown, throughout the whole 
civilized world, such a material decrease in the percentage of 
deaths from diphtheria where antitoxin has been used that the 
evidence of its value cannot be neglected, however much it may 
be questioned. Only last week one of the best-known prac- 
titioners in New York City, who has given special attention to 
this subject, both in this country and abroad, made a most bitter 
attack upon antitoxin as a therapeutic agent, the same writer 
having taken the same stand early in the days of antitoxin 
therapeusis. There were several others at this meeting who 



DISEASES OF THE PHARYNX. 369 

gave their support to the speaker's views, and the question, 
therefore, becomes again one for earnest consideration and 
discussion." 

In an article published in June, 1896, J. M. French, in 
reviewing the first year of the antitoxin treatment, maintains 
that the harmless character of the serum has been demonstrated 
in more than 100,000 injections. 

" Taking all cases reported together, the practical result of 
the first year's use of antitoxin, so far as can be judged at the 
present time, has been to lessen the death-rate from diphtheria, 
in cases where it has been used, nearly or quite one-half, thus 
proving itself beyond all doubt to be the most successful of any 
known treatment for this dread disease. It is confidently pre- 
dicted that the results will be even more favorable the second 
year, owing to improvements in the methods of preparing, pre- 
serving, and administering the serum. There is also every 
reason to anticipate that the same success which now attends 
the treatment of diphtheria by the serum method will soon be 
attained in the cases of a number of other specific diseases." 
{Medical and Surgical Reporter.) 

The opinions and practice of Chicago general physicians 
are fairly represented by the following extracts from communi- 
cations to the editor of the North American Practitioner, J. H. 
Hollister, and published in April, 1896 : — 

H. M. Lyman : " I have seen no cases of diphtheria since the intro- 
duction of the antitoxin treatment of the disease, but, whatever may be 
concluded regarding the antitoxin treatment, there are certain measures 
that should never be neglected in the management of diphtheria : 1. The 
maintenance of general and local cleanliness by means of gargles, injec- 
tions, vapors, and sprays, so far as they can be used without risk of 
exhausting the patient, or terrifying him if a } T oung child. 2. The sus- 
tentation of strength by the frequent administration of milk, broth, eggs, 
and alcohol. 3. The encouragement of renal and intestinal elimination 
by the use of mercurials in small and frequent closes. 4. The avoidance 
of all drugs that are disagreeable and irritating, such as the tincture of 
the sesquichloride of iron, quinine, etc. 

"During the period of convalescence, especial^ if the patient has 
passed the period of infancy and early childhood, the treatment may be 
conducted in accordance with general principles. The occurrence of 

24 



370 DISEASES OF THE EAR, NOSE, AND THROAT. 

paralysis calls for special treatment of the neural inflammation by which 
it is caused." 

Wm. E. Quine : " Local Treatment. — None except poultices, which 
are recommended when there is much swelling of the lymphatics. I dis- 
approve strongly of the use of the brush and probang, and have come to 
regard the atomizer with indifference. 

" Internal. — In ordinary pharyngeal diphtheria my routine treat- 
ment consists of the administration of the tincture of iron, — 1 drachm 
in an ounce of a mixture of glycerin and syrup. Of this a teaspoonful 
is given for a dose, and never less than half a teaspoonful, even to an 
infant, every two hours or every hour, according to the severity of the 
case. The medicine is given undiluted, and no drink is permitted imme- 
diate^ after it. The object is to have it adhere to the affected parts. 
In case vomiting occurs, ^ or J minim of carbolic acid is added to each 
dose; and if vomiting persist, which is rarely the case, the treatment is 
stoutly maintained, nevertheless. Corrosive sublimate, chlorate of po- 
tassium, whisky, and quinine are not, in my opinion, important additions 
to the treatment. Laxatives are given as required. Recumbency is 
enjoined. Feeding is attended to with urgent insistence. 

" Antitoxin. — My experience has been limited to its use in eighteen 
cases of nasal and laryngeal involvement. In such cases I employ it 
at once, — ' Behring's No. 2.' I have not witnessed a failure, and have 
not seen any harmful result beyond the appearance of a transitory erup- 
tion on the skin in two or three cases, and the occurrence of transitory 
albuminuria in a like manner ; but, nevertheless, my respect for the 
observations of others, recorded and unrecorded, in relation to untoward 
events which must be ascribed directly to the influence of the antitoxin, 
holds me to a preference for the iron mixture in cases of uncomplicated 
pharyngeal diphtheria. 

" Formerly I regarded the atomizer as an important aid to treat- 
ment, especially of diphtheria of the larynx, and antiseptic injections, 
such as a weak sublimate solution, repeated every two or four hours, as 
indispensable to the efficient treatment of nasal diphtheria; but for t-he 
past year or so I have been falling away from these measures and relying 
on the antitoxin." 

J. A. Robison : " Prior to the introduction of the antitoxin treat- 
ment it was trul3 r said: 'there is no specific treatment for diphtheria.' 
But my experience recently in the use of antitoxin in five cases of true 
diphtheria has converted me to the belief that it is a specific. Antitoxin, 
in nry -opinion, is the prince of remedies. Yet there are cases in which I 
would not cease to emplo}^ the older methods of treatment." 

Frank Billings : " General Treatment. — The temperature of the 
patient to be controlled by frequent bathing with water. The bowels 
should be freely evacuated in the first twentj^-four hours by the use of 
calomel combined with sodium bicarbonate, in doses graded to the age of 



DISEASES OF THE PHARYNX. 371 

the patient. Strychnia sulphate, in doses graded to suit the age of the 
patient, from the beginning to the end of the disease, as a general and as 
a cardiac tonic. Alcohol, in the form of sherry-wine, whisky, brandy, or 
rum to be used only in cases of great toxaemia, in frequently-repeated 
small doses, when used at all. In the great majority of cases it is not 
necessarj 7 , and I think it should be reserved as a final antitoxin. A diet 
fluid in form of milk, milk and egg, animal broths, gruels, koumiss, 
matzoon, or any modified milk. 

"Local Treatment. — The following plan gives me great satisfaction : 
A thorough cleansing of the pharynx and naso-pharynx with a solution 
of H 2 2 : for the pharynx diluted two or three times, for the nose and 
naso-pharynx five or six times ; by having the patient gargle or by 
spraying the pharj-nx, and b} r syringing the naso-pharj'nx through the 
nose. I believe in applying treatment through the nose as well as upon 
the pharynx in all forms of throat diphtheria. After cleansing with 
H 2 2 I use 

R Hydrarg. chlorid. corrosivi, . . . gr. T ^ to -£-§. 

Sacchari albi gr. iii to v. 

Misce ; triturate. 
Ft. chart, no. j. 
Signa : Apply dry upon the tongue every hour. 

" This does very well with all patients, and with children is taken 
readil} 7 ; it is applied directly to the pharynx and is also an efficient con- 
stitutional remedy and laxative. It is to be withdrawn if diarrhoea or 
bloody-mucous stools occur. 

" To the nose, after cleansing, appty with a syringe a solution of 
corrosive sublimate in water, 1 to 10,000, every two hours. 

" A steam-spray should be kept playing almost constantly over the 
head of the patient. 

R Acidi carbolici, 3j- 

Zinci snlphocarbolatis, 3j. 

Glycerini, gj. 

Aquae, q. s. ad ^iv. 

Misce. Signa : To be used in the steam-spray atomizer ; or 

R Glycerini, gj. 

Aquae calcis, 3iij. 

Misce. Signa : Use in the steam-atomizer. 

" These solutions remain suspended in the air quite a time, and 
seem to afford the patient much relief. 

" In case corrosive sublimate cannot be borne, I consider tr. ferri 
chloridi, 5U ; glycerini, §j ; aquae, giijj may be used in place of it; 3j 
every hour. 



372 DISEASES OF THE EAR, NOSE, AND THROAT. 

" I consider antitoxin of great benefit in all cases, — greatest when 
used early in the disease. A maximum dose should be used in all cases 
and should be repeated within twelve hours. I would not hesitate to use 
it in a case, no matter what the complication. I believe, however, in 
carrying out a thoroughh T -planned local and general treatment, even 
when the antitoxin is used." 

A critical review of the great mass of evidence accumu- 
lated, both favorable and unfavorable, to the blood-serum 
therapy, a small fraction of which is here presented, forces the 
conclusion that the preponderance of evidence justifies the ver- 
dict that diphtheria antitoxin, administered early and in sufficient 
doses, — the first or second or not later than the third day of the 
disease, — has the power to prevent a fatal issue. Given later 
it may modify the intensity of the toxaemia if a multiple of the 
ordinary dose is given. 

Mixed infection, and invasion of the larynx demanding 
intubation or tracheotomy, lessen the chances of recovery. 

While the serum is a powerful remedy and may be capable 
of doing harm, the disease itself is so virulent that, in view of 
the great weight of testimony and statistics in favor of the anti- 
toxin, the physician should not fail to avail himself of this 
addition to thorough local and general treatment. 






CHAPTER XXXII. 
DISEASES OF THE PHARYNX, CONTINUED. 

Tonsillitis. 

Synonyms. — Quinsy ; amygdalitis ; phlegmonous sore 
throat ; angina tonsillaris ; ulcerative tonsillitis ; suppurative 
tonsillitis; abscess of the tonsil. 

Pathology. — This is an acute inflammation of one or both 
tonsils. There are three principal varieties: (1) simple catarrh, 
(2) ulcerative tonsillitis, and (3) abscess of the tonsil. 

Some authorities distinguish five varieties of this disease, 
but practically they are all variations of three types of inflam- 
mation. The inflammatory action may be of a mild catarrhal 
character and limited to the mucous membrane, or it may 
eventuate in superficial ulceration, or it extends to the sub- 
mucous tissues, with infiltration of the whole gland and the 
peritonsillar connective tissue. In the second and third forms 
the lacunae,, or crypts that indent the surface of the tonsil, are 
filled with micrococci, pus, and epithelium. 

Tonsillitis is most frequent in persons between the ages of 
15 and 30 years, and especially among those of a rheumatic 
habit and with hypertrophied tonsils. The inflammation 
usually involves to a greater or less degree the pillars of the 
fauces and the uvula. They are red and swollen and the uvula 
elongated and troublesome (Plate V). The attack may termi- 
nate in resolution, ulceration, abscess, or hypertrophy. In the 
case of an abscess it may rupture near the superior and anterior 
portion of the tonsil in the vicinity of the arch of the palate. 
The orifices of the crypts may become obstructed, with the 
result of distending these cavities with the pent-up secretions. 

With regard to the bacteriology of tonsillitis, it cannot be 
said, at the present time, that the various forms of tonsillitis are 
caused by any special organism, although they may be traced to 
a microbic infection. A. Veillon {Archives de Medecine, March, 

(373) 



374 DISEASES OF THE EAR, NOSE, AND THROAT. 

1894) concludes that " pathogenic microbes may be found in all 
forms of non-diphtheric tonsillitis. The streptococcus pyogenes 
virulens was present in the twenty-four cases examined, and was 
usually associated with the less virulent pneumococci and some- 
times with staphylococci. The streptococcus appears to play the 
most important role in all cases. The different kinds of tonsil- 
litis are of the same nature. The clinical and anatomical differ- 
ences depend upon (1) whether the organisms affect the surface 
of the mucous membrane, its deeper layers, or the subjacent 
cellular tissue, and (2) the virulence of the microbes and the 
resistance of the subject." 

Etiology. — While tonsillitis is not usually met with in 
persons younger than 15 or older than 30 years, I have seen it 
above the fiftieth year. No age is absolutely exempt. Rheu- 
matism is an important factor in the production of this disease. 
A close relationship is often observable between attacks of tonsil- 
litis and rheumatism, one following or preceding the other — one 
subsiding as the other develops. Cold, damp, foggy, or change- 
able weather is a predisposing cause ; the presence of hyper- 
trophy and the history of previous attacks presage future ones. 
Unusual exposure is a frequent excitant of this as it is of other 
inflammations. The crypts are often found filled with caseous 
masses that excite inflammatory action. These cheesy plugs 
undergo decomposition and become acrid, irritating, and foul- 
smelling. 

Symptomatology. — Premonitory symptoms are : a heavy 
feeling akin to exhaustion, followed by a sense of feverishness, 
headache, and pain in the back and legs. Chilliness may be 
present during the first few hours and the temperature may rise 
to 103° or 105° F. by the second day. If the fever is very high 
it indicates that the deeper structures are likely to become the 
seat of an abscess. As the disease progresses, the tonsil becomes 
swollen and obstructive to deglutition; sensations as if a foreign 
body were in the throat, together with increased secretion of 
mucus, occasion frequent efforts to free the throat by swallow- 
ing, which becomes more and more difficult. All the surround- 
ing tissues now participate in the inflammation in the severe 



DISEASES OF THE PHARYNX. 375 

type so that the velum and uvula are red, thickened, and sensi- 
tive. The elongation of the uvula to the extent that it hangs 
upon the tongue (Plate V) adds to the excitants of painful 
deglutition. When the inflammatory action extends to the 
orifices of the Eustachian tuhes and to the pharyngeal tonsil, 
impaired hearing, ringing, and even pain in the ears ensue. 
These symptoms represent the crisis of the simple catarrhal 
form of a severe character, and now begins an abatement of the 
inflammation, subsidence of the pain, swelling, difficult swallow- 
ing, and the membrane begins to assume a more natural color. 

In the second, or ulcerative, form, instead of an ameliora- 
tion of all the symptoms at the crisis of the inflammation, the 
mucous membrane softens and breaks down in spots. The 
surface of the gland is dotted with small, yellowish-gray points 
(Plate V) that coalesce and form irregular ulcers covered with 
a muco-purulent discharge. I have known physicians to mis- 
take this coating of the ulcers for a diphtheric exudate, but 
the deposit can be seen at first as limited to the orifices of the 
lacunae, and there is a wide difference between the two, even in 
macroscopic appearances. 

When the inflammation extends to the deeper structures 
speech is seriously interfered with, and it is difficult to articulate 
with sufficient clearness to be understood. The mouth cannot 
be opened on account of the pain and tumefaction about the 
angle of the jaw, and it may be well-nigh impossible to examine 
the pharynx, even with the aid of the forehead-mirror and 
tongue-depressor (Plate V). In this stage cold sweats and 
sleeplessness are sometimes experienced. Liquids regurgitate 
into the nose or find their way into the larynx, occasioning most 
violent fits of coughing and strangling. The cervical muscles 
sometimes become sore and tender on pressure. The continuous 
exertions necessary to clear the throat of secretions, which are 
not swallowed, but allowed to slaver from the mouth, serve to 
increase the distress. When the uvula can be seen, it is found 
clinging to the affected tonsil. While the secretion of saliva is 
increased, the urine is diminished in quantity and of high color. 
The breath becomes freighted with a fetid odor and the tongue 






37b" DISEASES OF THE EAR, NOSE, AND THROAT. 



is furred with a yellowish-gray coat. The bowels are generally 
constipated. 

Mild attacks of tonsillitis may not extend beyond a week, 
but the severe form, which terminates in an abscess, is a tedious 
type. In the course of a week or ten days a chill denotes the 
formation of pus, and a little later, if the abscess is not opened, 
it breaks, usually in the throat, However, it may rupture 
externally at the angle of the jaw, or burrow underneath the 
cervical muscles, forming an abscess of the neck, or it may 
gravitate to the thoracic cavity. 

Diagnosis. — The characteristic symptoms described render 
a diagnosis comparatively easy. There is not much likelihood 
of confounding this disease with any other except diphtheria. 
In the latter disease the tonsils are not always swollen, and the 
false membrane is thick, leathery, and of much lighter color 
generally. Yet it must not be forgotten that the Klebs-Lofrler 
bacillus is sometimes found in the throat when there is no false 
membrane ; so that in suspicious cases a bacteriological exam- 
ination should be made. In the sore throat of measles and 
scarlet fever the distinguishing rash, the ease of opening the 
mouth, and the comparatively little enlargement of the tonsils 
clear up any doubt. Syphilitic sore throat does not present the 
intense group of symptoms of severe tonsillitis, and can be 
differentiated from the mild catarrhal form, in that fever and 
pain are generally absent and the difficulty of swallowing is 
not so prominent a symptom. Patches of redness, instead of 
the bright, diffused, red glow of acute tonsillitis, characterize 
the early stages of syphilis, while the secondary stage is mani- 
fest in the mucous patches and skin eruptions, and the tertiary 
stage in the deep ulcerations and an unmistakable history. 

Prognosis. — Simple catarrhal- tonsillitis usually terminates 
in resolution, running a course of about a week. It is often 
preceded or followed by a rheumatic attack of other structures, 
and may end in tonsillar hypertrophy. Ulcerative tonsillitis 
also tends toward recovery, but the possibility of invasion of 
other parts, such as the Eustachian tube and tympanic cavity, 
emphasizes the necessity for efficient treatment. Occasional 



""' 



DISEASES OF THE PHARYNX. 



377 



deaths have occurred from tonsillar abscess breaking into the 
larynx or causing laryngeal oedema. The occurrence of an 
abscess lengthens the attack to two or three weeks and some- 
times longer. 

Local Treatment — Local applications of glycerin of tannin 
have proven effective in the simple catarrhal tonsillitis. I am 
aware of the opposition to this treatment by high authority 
(Lennox Browne), but I cannot ignore years of actual satis- 
factory experience with it. I have made it a practice to apply 
this remedy with a very soft, bushy camel's hair pencil every 
two or four hours. If there is considerable pain, a 10-per-cent. 
solution of carbolic acid in glycerin will afford a local anaes- 
thetic effect, besides depleting the vessels and acting as an anti- 
septic. I have found local applications of guaiacol useful. It 
appears to shorten the attack. If the pure drug is painful, it 
can be diluted one-half with glycerin. Gargles of alum-water 
and potassium bromide in 4-per-cent. solutions are grateful in 
some cases. Much refreshing relief is experienced after copi- 
ously spraying the throat with benzoinated lavolin or a 3-per- 
cent, solution of camphor-menthol (Figs. 118 and 119). The 
author's throat tablets have given excellent satisfaction. Each 
tablet contains 



& Amnion ii chloridi, 

Tincturae opii camplioratoe, 
Syrupi scillse compositi, 
Syrupi Tolutani, . 
Extvacti glycyrrhizse, . 



;•■• '.]■ 



aa ITlv. 

. gr. iiss. 



These are allowed to melt slowly in the mouth, so as to 
prolong the contact of the remedies as much as possible with 
the inflamed membrane. 

Ulcerative tonsillitis should be treated with alkaline dis- 
infectant and antiseptic topical applications. Frequent sprays 
of hydrogen dioxide (peroxide), Dobell's and Seller's solutions, 
glycothymolin, listerin, paste urin, borolyptol, etc., will cleanse 
and disinfect the glands, after which a covering of aristol 
should be given with the powder-blower (Fig. 32). 

If an abscess is indicated by the severity of the symptoms, 



378 DISEASES OF THE EAR, NOSE, AND THROAT. 

local cold should be used early by means of an ice-bag (Fig. 
78) directly over the tonsil. As soon as the abscess can be 
discerned it should be opened instead of waiting for nature to 
accomplish this. Several days of extreme wretchedness will be 
spared the sufferer by this means. The knife should have a 
handle sufficiently long to not hamper one in his movements. 
The cutting-edge must be kept toward the median line so as to 
avoid wounding the internal carotid artery, which might occur 
by a sudden movement of the patient if the cutting edge were 
directed toward the artery. The abscess usually points near the 
arch of the anterior faucial pillar. 

For phlegmonous tonsillitis Gouguenheim {Lyon Medical, 
1894) recommends Leiter's coil around the throat, leeches to the 
angle of the jaw, 20- to 33-per-cent. cocaine painted in the 
pharynx, irrigations with warm boric-acid solution, and salol or 
naphthol internally for an intestinal antiseptic. 

Tonsils that are subject to recurring attacks of inflamma- 
tion should be guillotined (see division on tonsillotomy). 

Constitut'umal Treatment. — When the pain is severe and 
swallowing difficult, I have seen the most gratifying relief 
attend the administration of a combination of morphia with 
atropia in the proportion of \ grain of morphia to ¥ ^ grain of 
atropia. This remedy relieves pain and irritability, dries up the 
excessive secretions that constantly excite efforts to swallow, and 
modifies the intensity of the inflammatory process. Patients to 
whom I have administered this for the first time, and who have 
been in the habit of passing through similar attacks for years, 
have remarked with unfeigned gratitude that they had never 
before received sucli relief from suffering during a siege of their 
malady. A laxative should be given at the onset of the attack, 
so as to open the bowels freely. Aconite enjoys quite a repu- 
tation in this disease, given in doses of 2 or 3 drops every 
half-hour. Potassium bromide, mentioned in connection with 
local treatment, has a beneficial sedative effect if some of it is 
swallowed after gargling with it, so that 10 grains every two or 
three hours are taken. 

The rheumatic character of this affection calls for such 



• 



DISEASES OF THE PHARYNX. 379 

remedies as salicylic acid and antipyrin. If there is no reason 
why salicylate of sodium should not be given, it is to be pre- 
ferred. When it is well borne I give 10 grains every two hours 
until the symptoms become ameliorated or slight physiological 
effects are produced. A freshly-prepared solution should be 
used, for example, as follows : — 

& Acicli salicylici, 3iij- 

Sodii bicaruonatis, 3ij. 

Elixiris gaultheriae, ^ss. 

Glycerini, 3iij. 

Aquse, q. s. ad 3iv. 

Misce. Signa : One teaspoonful, iu water, every two hours. 

If salicylate of soda disagree with the stomach or cause 
ringing in the ears, salicin should be substituted in pilular form, 
5 grains to be taken every two or four hours. 

Antipyrin in doses of 5 or 10 grains every three or four 
hours not only relieves pain, but possesses especial efficacy in 
rheumatic affections. 

Hypertrophy of the Tonsils. 

Synonyms. — Enlarged tonsils ; chronic tonsillitis ; follicular 
tonsillitis. 

Pathology. — Hypertrophy of the tonsils is a true hyper- 
plasia, according to Virchow, in which all the glandular ele- 
ments participate in the proliferous process. The increase and 
induration of the connective tissue is manifest in some tonsils at 
the time of excision, by the resistance to the passage of the 
guillotine through them, but in most instances they are yielding 
and sponge-like. The crypts are expanded and the walls tume- 
fied. Instead of a tenacious mucus filling the cavities there are 
often cheesy masses of a light-yellow color sometimes mixed 
with calcareous concretions. There is an increase in size and 
usually in number of the follicles surrounding the depressions. 
Norris Wolfenden {Journal of Laryngology, etc., August 18, 
1894) reports the results of studies in follicular tonsillitis as 
follows : " Follicular tonsillitis is a desquamative process in the 
crypts of the tonsils, the follicles taking no part in the process 



380 DISEASES OF THE EAR, NOSE, AND THROAT. 






and only exhibiting a secondary hypertrophy, as recently main- 
tained by Sokolowski and others. There are other forms of 
infective tonsillitis associated with the exudation of fibrin, the 
presence of streptococci, staphylococci, and pneumococci." 

In the follicular, or lacunar, tonsillitis the pseudomembrane 
shows staphylococci and streptococci and the pseudodiphtheric 
bacillus. It cannot always be distinguished from diphtheria 
except by bacteriological examinations. 

Kriickmann (Virchow's Arcliiv) confirms Hanau and other 
observers in the view that the tonsils are the portal of entrance 
for tubercle bacilli in cases of tuberculosis of the cervical 
lymphatic glands. 

Etiology. — Hypertrophied tonsils are found in the very 
young so often that they may be spoken of as being congenital, 
but in many instances they develop about the age of puberty. 
The largest number of cases are seen between the ages of 10 
and 20 years, the next largest under the tenth year, and those 
occurring between 20 and 30 years are next in frequency. 
After the thirtieth or fortieth year tonsillar hypertrophy is rather 
infrequent, for their growth ceases and the process of atrophy 
sets in about the thirty-fifth year. Nearly twice as many males 
are affected as females. 

The rheumatic habit ; living in a damp, cold atmosphere ; 
recurring attacks of inflammation, the throat complications of 
the eruptive diseases, diphtheria, syphilis, and the strumous 
diathesis are all productive of those conditions that predispose 
to an increase in the volume of these glands. After the thirty- 
fifth year I do not advise the removal of the tonsils unless there 
is some special reason for it, since their gradual diminution in 
size and tendency to inflame dates from about this period of life. 

Symptomatology . — The appearance of a child with enlarged 
tonsils often presents a picture which suggests at once the nature 
of the trouble. Previously to an examination of the throat one 
is often able to predict the condition to be found. The under jaw 
drops, the mouth remains continuously open, the eyelids droop, 
and the face is expressionless and suggestive of a dull intellect. 
During sleep the respiration is noisy and of a snoring character. 



DISEASES OF THE PHARYNX. 381 

Associated with hypertrophied tonsils in a large proportion of 
children so affected will be found an enlargement of Luschka's 
tonsil, or adenoid vegetations in the vault of the pharynx. In 
these associated diseases with obstruction to the current of air 
through the nose by adenoids and the backward projection of 
the oral tonsils, and to the passage of air through the mouth by 
the blocking up of the fauces with the oral tonsils, the aeration 
of the blood is seriously interfered with. The effects on the 
voice are readily apparent. The resonance of the nasal cavities 
is so diminished that speech has a thick, unnatural nasal 
quality, and the articulation of words is impeded and difficult 
(Fig. 148). 

The tonsils are situated in such close relationship to the 
Eustachian orifices that any disease of the gland threatens im- 
pairment of the integrity of the Eustachian tubes and middle 
ears. While the tonsils are not so situated as to produce actual 
pressure upon the tube-mouths, as was formerly supposed, any 
inflammatory action affecting the gland readily extends by con- 
tinuity to the tubal membrane. The large number of patients 
with hypertrophied tonsils suffering from middle-ear diseases 
is suggestively significant. Mackenzie and others speak of 
defective smell and taste in tonsillar hypertrophies. 

Great embarrassment of the respiration may interfere seri- 
ously with the general health, and in very young persons, or 
those with a tendency to rickets, the chest-walls may become 
deformed, resulting in pigeon-breast, or a pyriform deformity. 

Inspection of the throat reveals the tonsils tumefied (Plate 
V) and in some instances so enormously enlarged as to lie in 
contact with each other and to cut off a view of the posterior 
wall of the pharynx. They are generally very red, soft, and 
yielding, and can be crowded through the fenestra of a tonsillo- 
tome so small that it would seem impossible. 

Diagnosis. — A view of the pharynx under good illumina- 
tion is sufficient to establish the diagnosis. There is a possi- 
bility of mistaking an enlarged tonsil for a pharyngeal abscess, 
but the chances are remote. The location of the tonsil and, if 
necessary, palpation with one finger on the tonsil and another 



382 DISEASES OF THE EAR, NOSE, AND THROAT. 






over its base under the angle of the jaw, would distinguish the 
location and character of the tumor. 

Prognosis. — Probably the vast majority of hypertrophied 
tonsils are never removed or even treated, yet it is the exception 
to see them after the thirtieth or fortieth year. This means that 
there is a natural reduction to the normal size after adolescence 
or middle life. However, there are many individuals with im- 
paired hearing that is attributable either directly or indirectly to 
the presence of tonsils that have been subject to repeated attacks 
of inflammation. In adult life I rarely advise their removal 
unless they are provocative of some disturbance, for in many 
they occasion no inconvenience. But I have seen persons in 
middle life who were subject to so much suffering from attacks 
of quinsy that they sought relief by excision. It must not be 
forgotten that the lacunae of the tonsils, from twelve to eighteen 
in number for each gland, offer nides for the reception and 
culture of micrococci that may give rise to more serious trouble. 
These depressions are sometimes very deep, plunging down 
into the parenchyma of the gland, and form an ideal nest for 
the development of micro-organisms. There are warmth, 
moisture, decomposing secretions, and a harbor from the cur- 
rents of air or friction of fluids and food that might otherwise 
dislodge them. 

Treatment — Iodine internally, astringents to the surface of 
the tonsil, and injections of various drugs into the body of the 
gland are recommended for its reduction, but they are all inane 
makeshifts that worry the patient without benefit to any one but 
the doctor. The tonsil should be removed in its entirety. My 
aim has always been to cut it clean off at the base so as to get 
below the bottoms of the crypts and leave a smooth surface for 
the stump. 

Tonsillotomy. — Before operating for excision of the tonsil 
the throat should be sprayed with an antiseptic wash, such as 
dioxide of hydrogen or mercuric bichloride, — 1 to 10,000, — to 
remove or destroy any microbes that may be present. I rarely 
paint the parts with cocaine, for the reason that it is not a very 
painful operation. The gland is not freely supplied with nerves 



DISEASES OF THE PHARYNX. 



383 



of sensation. But in very finical individuals it may be neces- 
sary to employ a weak solution for the purpose of a placebo. 
Occasionally I have been obliged to use the bromide of ethyl, 
removing both tonsils and adenoids during one anaesthesia. 

The patient, if a young child, is seated on the lap of an 
assistant or a nurse. One arm of the latter pinions the arms of 
the child, and with the other hand the patient's head is held 
back against the nurse's shoulder by pressure on its forehead. 
A convenient method is to infold the child in a sheet, which is 
made to fix immovably the arms and legs (Fig. 150). Now the 
tonsillotome (Fig. 155) is introduced into the mouth like a 




Fig. 155.— The Author's Tonsillotome, with Excised Tonsil. 



tongue-depressor, then slipped to one side with a turn that 
causes the ring of the opening to surround the tonsil. Suf- 
ficient pressure is then brought to bear to cause it to embrace 
the tonsil at its base. An assistant should press with his thumb 
or finger upon the side of the neck just over the base of the 
gland so as to prevent it from receding from the instrument. 
This counter-pressure need not be great, but simply sufficient 
for support. As the instrument is pressed into position, the 
operator's thumb drives the blade through the gland until the 



384 DISEASES OF THE EAR, NOSE, AND THROAT. 

cutting-edge of the guillotine rests between the ring-plates. 
This act completely severs the tonsil and secures it between the 
bevel of the knife and the upper ring-plate. Care must always 
be taken to cut the tonsil clear through before withdrawing the 
instrument. 

Tonsillotomes. — Any physician who has had a considerable 
experience in tonsillotomy with the various tonsillotomes will 
not be likely to deny that these instruments are generally too 
complicated. They are armed with needles, barbs, or sharp- 
toothed forceps for piercing the tonsil and dragging it through 
the fenestra before any cutting is done by the blades. A tonsil- 
lotome constructed after the pattern I have made renders the 
barbs unnecessary. It reduces the painfulness of the operation 
by one-half; it divests the procedure of any danger of an accident 
to the operator or patient; it makes a skillful and easy operation 
possible with a minimum amount of experience ; it resembles a 
large, folding tongue-depressor so closely that children usually 
offer no opposition to its introduction for the removal of the 
first tonsil ; and it combines strength and compactness with 
simplicity of construction. It is made on the principle of a 
guillotine, the blade of which is propelled by the thumb of the 
same hand that grasps the handle. The latter is set at such 
an angle to the shaft as will permit the most perfect co-ordinate 
action of the muscles of the hand and arm of the operator. 
All the work may be done with one hand. This advantage is 
not a small one, for two reasons : the powers of co-ordination 
and antagonism of muscles are far more perfectly under control 
in operating an instrument which requires but one hand than 
they are when both hands must co-operate, and one hand of the 
operator is left free to hold the head of the patient, if necessary, 
as the dentist does in extracting a tooth. The advantages of a 
tonsillotome that can be operated entirely by one hand are about 
the same as in a tooth-forceps which does not require two hands 
to manipulate. I have had two sizes manufactured, the smaller 
having a fenestra of the calibre ordinarily found in such instru- 
ments, the other supplied with an aperture larger than the 
largest Mackenzie tonsillotome, while it is so compactly con 



;on- 



DISEASES OF THE PHARYNX. 385 

stmcted as to require less space in which to operate. I have 
used the larger size to extirpate enormously hypertrophied ton- 
sils in children as young as 2J years, where it was impossible 
to insert the Mackenzie instrument of the necessary size. The 
smaller one is sufficient for the majority of cases, but the fen- 
estra is not capacious enough to admit the bases of the extraor- 
dinary glands we occasionally see. It is advisable to remove 
the whole tonsil, and, as the tops only of the largest tonsils can 
be severed with the smaller instruments, it may be better to 
have the larger size, if but one is to be kept. 

The blade is so protected as to make it impossible to wound 
the ascending pharyngeal or the internal carotid artery. The 
shaft that propels the blade is of such a width as to make the 
use of a gag unnecessary, for it protects the finger of the oper- 
ator from the patient's teeth, if it is placed in the mouth to 
ascertain when the fenestra is in such a position as to embrace 
the whole tonsil, as it is necessary for one to do when operating 
in children with other tonsillotomes. Since I have used this 
guillotine I have not had my finger bitten, while it was not an 
uncommon occurrence, before, to come off second best so far as 
pain was concerned. With the shank wide enough to afford 
protection, it is unnecessary to introduce the finger into the 
mouth, for the teeth and lips cannot close enough to prevent 
the operator from seeing plainly the field of operation. There 
is no working in the dark or fear of damaging structures one 
does not wish to attack. 

The handle is firmly fixed to the shank with a hinge-joint 
and self-acting spring-lock; so that the fenestra can be pressed 
down about the base of the gland with any degree of power 
required. This feature dispenses with any necessity for hooks, 
forceps, needles, or barbs for spearing the tonsil. The latter, 
being a soft, fleshy mass, adapts itself to the shape of the 
fenestra and protrudes through it the instant its base is pressed 
around. The pain of spearing or tearing the tonsil by toothed 
or barbed accessories, designed to drag the gland through the 
fenestra before the blade cuts, excites the most vigorous strug- 
gling and resistance on the part of a child. Even when the 

25 



386 DISEASES OF THE EAR, NOSE, AND THROAT. 

utmost care has been exercised, the barbs have pierced the soft 
palate or the surgeon's finger, instead of the tonsil. Moreover, 
the gland always comes out with this instrument, the same as 
though barbs were used. There is another important advantage 
in having the handle attached to the shank with a hinge pro- 
vided with an automatic lock, for the cutting extremity of the 
instrument cannot be thrown out of your control by a disturb- 
ance of the coaptation of its parts. The last time I operated 
with a Mackenzie tonsillotome the child jumped just as I was 
placing the fenestra about the tonsil. The shank revolved upon 
the handle, leaving the latter in my hand, while the cutting-end 
was entirely displaced and removed from the vicinity of the 
gland. It is impossible for this improved tonsillotome to play 
such a trick. The handle contains a concealed spring-lock 
operated by a convenient thumb-plate. When this is moved 
downward, the hinge-joint is unlocked and the instrument 
folds upon itself like a pocket-knife, occupying the space of 
about one and one-fourth inches in width and thickness by six 
and one-half inches in length. Another pertinent point, that 
should not be neglected in this age of antisepsis, is the provision 
for cleansing and disinfecting the three pieces of which the 
instrument consists. By raising the proximate end of the hori- 
zontal top spring of the shaft and swinging it 90 degrees to 
either side it becomes disengaged from its lock and liberates the 
blade from the shank. This arrangement makes it as simple as 
possible for taking apart, sterilizing, and putting together again. 

In amputating the apex of a relaxed and elongated uvula 
the blade is inverted. It is claimed by some operators that the 
remnant of the tonsil will become atrophied if the apex only is 
clipped, but I have never been able to find a good reason for 
half-doing the operation. I have never seen any but healthful 
results from ridding the throat of the whole trouble at once. 

There are cases in which one may be in doubt as to 
whether the gland ought to come out or not, because there is 
but slight hypertrophy, and the appearance of the throat does 
not seem to warrant surgical interference. But those same 
glands may be honey-combed with deep, slit-like crypts that are 



DISEASES OF THE PHARYNX. 387 

packed with inspissated, decomposing, irritating, caseous secre- 
tions that start the attacks of sore throat that make the patient's 
life a burden. 

It is a good rule never to part with the patient until one is 
sure that all oozing of blood has ceased. I have seen only one 
case of very severe haemorrhage, but as a number of such in- 
stances are on record we must always be alert for them. In the 
case of a student at the Illinois Medical College, a young man 
of 24 years, I had my first experience with profuse haemorrhage 
from this procedure. After I had operated on a number of 
children during the clinic and had sent them to the treatment- 
room to wait until all signs of bleeding ceased, the student re- 
quested me to operate on one of his tonsils. On examination 
I found it only slightly hypertrophied, and remarked that I did 
not generally remove glands so little enlarged. However, he 
insisted that he had suffered all his life from recurring attacks 
of inflammation, and was anxious to part company with the 
cause of them. Thereupon I excised it, but was struck with the 
very unusual amount of resistance offered to the cutting-blade. 
It seemed like forcing it through creaking leather. 

As the student left the operating-chair I proceeded with my 
remarks to the class as follows : " The haemorrhage has entirely 
ceased in all the children and they can now go to their homes. 
I have removed a large number of tonsils in my various clinics 
and in private practice without seeing a case of persistent haem- 
orrhage. I have never had to use anything to stop the bleed- 
ing. It generally ceases within five or ten minutes sponta- 
neously. But in case of severe haemorrhage, what would you 
do ] Excellent remedies are to be had in a saturated solution 
of tannic acid in water ; an ice-cold gargle ; pieces of ice held 
in the back of the mouth in contact with the bleeding surface ; 
ice applied to the neck over the tonsil ; powdered alum rubbed 
into the tissues ; a strong solution of iron persulphate applied 
on cotton or with the finger ; 2 drachms of gallic acid with 6 
; drachms of tannic acid to the ounce of water ; pressure by for- 
ceps both externally and internally upon the tonsil, and firm 
compression of the common carotid artery. This compression 



388 DISEASES OF THE EAR, NOSE, AND THROAT. 

reduces the supply of blood to the tonsil-stump and encourages 
faintness, and with fainting the haemorrhage will probably cease. 

" There is more bleeding in this young man's case than I 
have ever seen. It does not diminish. In fact, there is a con- 
stant stream of blood flowing into the basin. It looks as though 
we were to have our first experience with a persistent tonsillar 
haemorrhage. I will send for ice, and exert firm, deep com- 
pression on the common carotid. The pallor of countenance 
and the beads of perspiration show the effect of the loss of 
blood. The profuse haemorrhage is probably due to the fact 
that the recurring attacks of inflammation during the past years 
have left the gland in an indurated, fibrous condition, which 
prevents collapse of the blood-vessels. There is no history of an 
hemorrhagic diathesis. We will deprive the vessels of their 
blood-supply until coagula form and plug their open mouths, 
and keep him in a sitting posture to assist in this and to pro- 
mote faintness. We will not allow him to gargle fluids for fear 
of washing away any clots that may form, but give pellets of 
ice instead. 

"It is now forty minutes since the tonsillotomy and all 
haemorrhage has ceased. The young man's room-mate will 
keep watch over him and inform us if there should be any re- 
turn of the trouble, although I do not anticipate it if he remain 
perfectly quiet in bed the remainder of the day. He complains 
of feeling faint. 

" This incident illustrates the necessity of always being pre- 
pared for emergencies. The most successful soldier, lawyer, or 
doctor is the one whom you can never surprise." 

The young man had no further haemorrhage and made an 
excellent recovery. After these operations patients are given 
a spray of camphor-menthol in lavolin, 3 per cent., for use at 
home four or six times a day until all soreness ceases. 

H. W. Loeb removes the tonsil with the hot snare. He 
believes that by removing only a small portion a cure through 
cicatricial contraction is effected. 

Jonathan Wright has devised a galvano-cautery instrument 
fashioned after the guillotine tonsillotome. 



CHAPTER XXXIII. 
DISEASES OF THE PHARYNX, CONTINUED. 

Mycosis of the Pharynx. 

Synonym. — Pharyngomycosis. 

Pathology. — This is a very rare parasitic disease of the 
superior pharyngeal space, including the tonsils. Small, white 
or yellow growths appear, projecting above the mucous mem- 
brane, instead of occupying a recessive position, as is the case 
with tonsillar concretions. They may invade the lacunae, but 
are not confined to them. They spread upon the soft palate, 
the pharyngeal membrane, and base of the tongue. As I have 
seen it, the growth is not soft like the cholesteatoma of the 
tonsil, but tough and somewhat difficult to remove in its en- 
tirety. It has, in some instances, a fungoid appearance, and 
penetrates the mucosa to such a depth as to prevent its removal 
with a probe. 

Etiology. — The cause of this disease is obscure, but the 
microscope reveals the leptothrix buccalis, which finds a habitat 
in carious teeth. 

Symptomatology. — No conspicuous symptoms are produced 
by this disease, but patients discover the growths accidentally 
and apply to have them removed. 

Diagnosis. — The diagnosis is easily made, since the symp- 
toms of inflammation characterizing pharyngitis, tonsillitis, etc., 
are wanting. It is distinguished from tonsillar concretions by 
the prominence of the growths and their location without the 
lacunae. 

Prognosis. — The tendency is not toward a spontaneous 
cure. The disease is very pertinacious and, like the regenera- 
tion of the drum-head, these growths often reproduce themselves 
as fast as they are removed. 

Treatment. — If caries of the teeth is found it must receive 
attention. Delavan uses the curette and follows this with the 

(389) 



390 DISEASES OF THE EAR, NOSE, AND THROAT. 

galvano-cautery. After removing the fungi the membrane 
should be sprayed with undiluted hydrogen dioxide or mercuric 
bichloride, 1 to 10,000. Each growth should be treated as has 
already been recommended for enlarged pharyngeal follicles, 
using cocaine and then cauterizing half a dozen points at 
one sitting. In a monograph on pharyngomycosis leptothricia 
benigna, published in the New Yorker medizinische Presse, 
December, 1886, Max Toeplitz reviews the literature of the 
subject. Carbolic acid, sesquichloride of iron, and the sublimate 
solution, 1 to 2000, are recommended. Toeplitz uses the curette 
and galvano-cautery. Homer M. Thomas reports success from 
the galvano-cautery. 

Concretions in the Tonsil. 

Pathology. — The crypts of the tonsil are sometimes filled 
with an accumulation of dried secretions that consist mostly of 
carbonate and 'phosphate of lime in the hard variety, and of a 
cholesteatomatous mass in the soft deposits. The latter consist 
of cholesterin, epithelial cells, pus-corpuscles and micro-organ- 
isms. The hard concretions are called chalky or cretaceous 
concretions or calculi, and the soft ones cheesy or caseous deposits. 
These conditions are comparable to certain diseases of the ear 
that have been considered : cretaceous deposits in the drum- 
head and cholesteatoma of the tympanic and mastoid cavities. 

Etiology. — Tonsillar deposits are due to an inflammation of 
the walls of the lacunae. 

Symptomatology. — The symptoms are not of a troublesome 
nature. A sensation of irritation or fullness, especially when 
swallowing, may be the only unusual thing to be noticed. The 
deposit can generally be seen as a cheese-like point, and several 
will likely be found by a careful examination. Sometimes they 
will be overlooked unless hunted for by a blunt-pointed probe to 
depress and bring forward the mouth of each opening. The 
difference in the consistence of the masses is readily detected 
by the sensation imparted through the probe. Patients often 
observe these concretions in their sputa, with which they have 
been expelled in the form of little, yellowish balls. Their pres- 




Fig. 156.— Adhesion of Soft Palate to the Posterior Wall of the Pharynx. 
The Resulting Diaphragm is Perforated Behind the Uvula. (The 
Author's Case.) 






DISEASES OF THE PHARYNX. 391 

ence is a menace to the health of the gland, for they degenerate 
into irritating excitants of inflammatory processes. 

Treatment. — With the tongue depressed these concretions 
are removed without much difficulty by the curette (Fig. 75). 
If they are reproduced the crypts should be treated to the hot 
electrode or some other cautery. 

Non-malignant Tumors of the Pharynx. 

Tumors of the pharynx are not of frequent occurrence. I 
have seen many papillomata springing from the velum palati 
and uvula, varying in length from five to ten millimetres, but of 
pretty uniform diameter, this being about one-half their length. 
Fibroid and fatty tumors are rarely found, but such cases are 
recorded. They take their origin from the mucous or sub- 
mucous tissue, from the lymphatic glands, or from the perios- 
teum of the base of the skull or vertebrae. 

Symptomatology. — A papilloma occasions no discomfort. 
The patient is not aware of its presence until informed by the 
examiner. If the growth attain a considerable size it embar- 
rasses respiration and swallowing, or, if it reach to the epiglottis, 
it provokes a cough. 

Treatment. — If papillomata give trouble they are easily 
removed by the snare or galvano-cautery. Other tumors must 
be treated similarly according to the exigency of each case. 

Adhesions of the Soft Palate to the Pharyngeal 

Walls. 

Adhesions of the soft palate to the posterior wall of the 
pharynx sometimes occur, as shown in Fig. 156 and Plate VI. 
In my case, shown in Fig. 156, the young lady's throat is divided 
into a superior and inferior portion by an adventitious mem- 
brane consisting of extensive adhesions between the posterior 
columns and arch of the palate, on the one hand, and the 
lateral and posterior pharyngeal walls, on the other. An oval 
aperture is seen behind the uvula, through which nasal res- 
piration takes place. The only inconvenience suffered is the 



392 DISEASES OF THE EAR, NOSE, AND THROAT. 

lodgment of particles of food behind the new membrane. This 
aponeurosis, or pharyngeal diaphragm, is the result of the 
throat affection attending scarlatina which she had when a 
small child. 

Uyulitis. 

Inflammation of the uvula is sometimes more intense than 
the inflammatory action affecting the remainder of the pharynx. 
The swelling, oedema, and elongation of the uvula then consti- 
tute the conspicuous features of the disease. It increases to 
several times its normal proportions and hangs pendent upon 
the tongue, down toward the larynx. In this condition it gives 
rise to frequent swallowing and coughing. 

Treatment. — If the uvula is much elongated (Plate V) it 
should be clipped, with care that not enough be amputated to 
leave it too much abbreviated when swelling recedes and con- 
traction takes place. I have known it to be completely removed 
by mistake, probably on account of the operator's poor sight, 
and the articulation of words Was perceptibly defective. On 
the other hand, I have known syphilis to destroy it without 
producing this effect. 

Malformations of the Uvula. 

There has recently been some discussion in the medical 
journals relative to a deformity of the uvula known as " bifur- 
cated" or " double" uvula, conveying the impression that it is a 
very rare anomaly. I have seen quite a considerable number of 
such instances and do not regard them as extremely rare or of 
clinical importance. The journal writers have advocated imme- 
diate amputation of the supernumerary appendage, but as I 
have never been able to elicit any information that they were 
the cause of suffering or trouble of any kind, and, as the owners 
of this extra appendage were entirely innocent of a suspicion 
that there was an unusual condition of their throats, I have 
never deprived them of this heritage. 

Papillary growths on the uvula are occasionally found, and 
should be removed if they cause irritation. 



Plate VI 



PLATE VI. 

Figure 1. — Male, set. 23; acute pharyngitis. 

Figure 2. — Male, set. 44 ; simple chronic pharyngitis. 

Figure 3. — Male, set. 21 ; follicular pharyngitis ; galvano-cautery to 
follicles. 

Figure 4. — Male, set. 67 ; atrophic, or dry, pharyngitis. 

Figure 5. — Normal appearance of pharynx, uvula, and palatal folds. 

e, Soft palate. o, Posterior pillar. 

/, Uvula. p, Anterior pillar. 

n, Posterior wall of pharynx. 

Figure 6. — Male, set. 23 ; tuberculosis of pharynx. 

Figure 7. — Male, set. 28 ; retropharyngeal abscess. 

Figure 8. — Male, set. 29 ; syphilitic ulceration of pharynx and soft palate ; 
mercury and iodide of potassium ; local applications of iodoform and morphia ; 
afterward cauterized with mitigated stick. 

Figure 9. — Male, set. 20 ; adhesion of soft palate to posterior wall of 
pharynx, following syphilitic ulcerations ; perforation of soft palate, enabling 
patient to breathe through the nose . 



[Note.— Represented as seen by gaslight. By daylight the red color appears 

much paler.] 



Plate 







F. Syous, Pmvt 



Burk&M c reir,Q e Lith.Ph* a 



diseases of the pharynx. 393 

Tuberculosis of the Pharynx. 

Tubercular invasion of the throat is of infrequent occur- 
rence. 

Pathology. — A granular condition of the mucous membrane 
of the pharynx, with areas of a gray color, precedes the break- 
ing down of the epithelial layer that ushers in the stage of 
ulceration. The ulcers are superficial, of irregular forms, and 
ill-defined. Like a granulating wound, they respond to the 
touch by bleeding. 

Etiology. — The throat invasion is generally secondary to the 
same affection of other organs. 

Symptomatology. — The cough, constantly-elevated tempera- 
ture and accelerated pulse, loss of appetite and the characteristic 
expression of countenance, pallor of skin, and habit of body 
point toward the invasion of the great white plague. If the 
lungs are involved there will be expectoration, with cough ; if 
not, the cough may be, at first, dry and hacking. The most 
conspicuous and distressing symptom is pain, especially during 
movements of the muscles concerned in deglutition and speech. 
The proper nourishment of the patient is interfered with by the 
difficulty and pain experienced in swallowing. He will refrain 
from taking food as long as possible, in order to escape the 
torture of eating. Inspection reveals the granular, or ragged, 
ulcerated condition of the mucous membrane already described 
(Plate VI). 

Diagnosis. — Tubercular throat must be distinguished from 
syphilitic ulceration. The history of syphilis and the family 
history of tuberculosis must be sought. The latter disease is 
usually one of adult life, while syphilis, especially the congenital 
form, may occur in children. Syphilis is not attended by fever, 
and generally not by pain or difficult swallowing. Its ulcers 
are clearly denned, with red areola and clean-cut borders pos- 
sibly undermined. The ulcers of tuberculosis are shallow, 
ragged, and pale. They differ from scrofulous ulcers in that 
the latter are deep, with well-marked borders, and pain, fever, 
and cough are generally absent, while the muscles of phonation 
and deglutition cause little or no pain by their movements. The 



394 DISEASES OF THE EAR, NOSE, AND THROAT. 

scrofulous affection occurs mostly in children in whom there are 
no evidences of tuberculosis. 

Prognosis. — This is an acute affection that proves quickly 
fatal from exhaustion. The average duration varies from six 
weeks to six months, but it may be prolonged much beyond the 
latter time. 

Treatment. — For the relief of the most prominent symptom, 
pain, Sajous strongly recommends the application of a 10-per- 
cent, solution of cocaine, after cleansing the ulcers with a borax 
solution of 1 per cent, in the form of a spray (" Diseases of the 
Nose and Throat," 1892). He deprecates cauterization with 
silver as more hurtful than beneficial. Steam-inhalations of hot 
infusions of opium, belladonna, hyoscyamus, and conium pro- 
duce a soothing, sedative effect and render swallowing less 
painful. A solution of creasote and menthol in lavolin, in the 
proportion of 2 per cent, of creasote to 10 per cent, of menthol, 
makes an excellent topical remedy. Iodoform insufflations 
have proven beneficial, but aristol is preferable. It is devoid of 
a disgusting odor and taste, is slightly anaesthetic, and adheres 
to the surfaces of the ulcers better than any other powder. 
Before applying any of these local remedies the discharges 
covering the ulcerated surfaces must be washed off by such an 
alkaline spray as Dobell's or Seller's. A solution of sodium bicar- 
bonate, 3 grains to the ounce, is also useful for this purpose. 
The cauterization of tuberculous ulcers by acetic acid, as 
practiced by Krause, is probably productive of more benefit than 
any other method. The ulcers are treated similarly to lupus. 
After cleansing and cocainizing them the acid is rubbed in by 
means of a cotton pledget, using a solution of 20- to 40-per- 
cent, strength, to begin with, and increasing the strength rap- 
idly to 80 and 100 per cent. As fast as the eschars become 
detached, which they do in a few days, the treatments are 
repeated, until the process of cicatrization is seen to begin. If 
the tubercular granulations are covered with mucous membrane, 
the latter must be incised to give the acid access to the lesions 
beneath. Heryng uses sharp curettes to scrape away projecting 
masses of tumefied tissues. 



DISEASES OF THE PHARYNX. 395 

Cicatrization sometimes follows this method, but close watch 
must be kept for renewed breaking out of the disease in either 
the cicatrices or at new points. 

J. Solis-Cohen condemns galvano-cauterization as injurious 
"except under the most skillful manipulation." 

Ingals uses either the following spray or morphine troches : — 

R MorphisB sulphatis gr. iv. 

Acidi tannici, 

Acidi carbolici, aa gr. xxx. 

Glycerini, 

Aquse dest., aa f ^ss. 

Tuberculin and tuberculocidin have not fulfilled the expecta- 
tions of the profession. The former has proven positively harm- 
ful, and since patients do as well under other forms of treatment 
as with the use of the latter, their employment is not recom- 
mended. 

Creasote has been largely used internally and applied 
locally in recent years, and, while undoubted benefit has accrued 
from its use in the hands of eminent practitioners, there are 
some who discourage its employment. However, in a disease 
so intractable, and discouraging to both patient and physician, 
as this must be admitted to be, whatever has proven beyond 
cavil and reasonable doubt to have been helpful in treatment is 
worthy of trial. Great caution is necessary in its administration 
to patients who have high temperature or haemorrhages. It is 
given in doses of 1 to 10 minims or more three times a day, 
preferably in milk, as recommended by Glasgow. It can be 
given at any time with reference to meals, but is best taken 
before meals if well borne, since it then exercises a preservative 
influence upon ingested food against the process of decompo- 
sition. The effect of this upon the promotion of nutrition is 
apparent. 

Creasote is readily taken in the form of capsules, or it may 
be combined with alcoholic or tonic preparations, as used by 
Cohen. 

The feeding of this class of patients is an important subject. 
When the high temperature does not forbid much animal food, 



396 DISEASES OF THE EAR, NOSE, AND THROAT. 

as much should be consumed as is consistent with good digestion. 
Milk, cream, codliver-oil, eggs, and vinous stimulants support 
the strength, improve nutrition, and prolong life. Added to 
these, the vegetable bitter tonics, iron, and quinine act as valu- 
able aids to enrich the blood and increase the general tone of 
the body. 

An out-door life in a high, dry, sunshiny, warm climate 
with equable temperature is conducive to the improvement of 
these patients, especially when combined with proper protection 
of the body by woolen underwear and a healthful employment 
of the mind and body in a cheerful or useful occupation. The 
most favorable climates are those of Southern California, Ari- 
zona, and New Mexico. Robert Levy says of Colorado : " I 
cannot add that our Colorado climate, so beneficial to pulmonary 
and, at times, to laryngeal phthisis, has any remedial influence 
upon pharyngeal tuberculosis. Miliary tuberculosis, with which 
tubercular ulceration of the pharynx is often associated, pre- 
sents'no encouragement in any climate, but in our high altitude 
it is my conviction that cases so afflicted decline very rapidly. 
The climate can only be of value in such cases as present no 
evidences of miliary tuberculosis or advanced disease, either 
local or constitutional." {Denver Medical Times, June, 1896.) 

Syphilis of the Pharynx. 

Although the throat is subject to the manifestations of 
syphilis in the three stages of that disease, the primary lesion is 
not often observed in this locality. The history of chancre in 
the pharynx is similar to that of the same ulcer in other 
localities, with a duration of about six weeks. The secondary 
lesions are of frequent occurrence and the characteristic mucous 
patches are readily recognized. The tertiary stage is repre- 
sented by the presence of gummata or eroding ulcers. The 
congenital form generally shows itself about five or six weeks 
after birth by the appearance of secondary lesions, and the 
tertiary stage at any time preceding the fifteenth or sixteenth 
year. 

Pathology. — Chancres are generally found on one tonsil, 




Fig. 157.— Destruction of Velum Palati. 



DISEASES OF THE PHARYNX. 397 

while the secondary and tertiary lesions show a special predi- 
lection for the soft palate. The syphilitic eruptions of the throat 
are similar to those occurring in other parts of the economy and 
are often coincident with them. In the early stage papular ele- 
vations make their appearance, the epithelial covering of which 
becomes eroded ; or erythematous patches occur in the form of 
a blush or mere hyperemia of transitory duration ; or the epi- 
thelium of these areas becomes exfoliated, leaving a denuded, 
pus-secreting mucous membrane beneath. These mucous 
patches now assume an ashy-gray color, with a rough, granular 
surface. They are eruptions of the secondary period of syphilis 
and extend their boundaries so as to invade a large territory in 
a comparatively brief period. They are surrounded by a red 
areola and a well-defined border, and there is a copious, yellow, 
purulent, nasty discharge from them. 

In the tertiary stage the ulcers are deeper than the mucous 
patches of the secondary period. The infiltration extends to 
the whole depth of the membrane and results in irregular thick- 
ening and induration in the form of nodules or gummata. If 
these are incised in the early stage they exude a glairy fluid. 
In time they degenerate into a caseous mass, which becomes sur- 
rounded by dense connective tissue. They are closely analogous 
to tubercle, but differ from the latter in their greater tendency to 
the formation of connective tissue. The increased proliferation 
of connective tissue produces pressure on the blood-vessels that 
supply the gummata with nutrition, thus cutting off their own 
nutrient sources. Breaking down and softening follow in each 
gumma, presenting a yellow spot which is soon the seat of an 
ulcer. 

The mucous patches of the secondary stage are superficial 
and may end in resolution with contraction of the tissues as the 
cicatrix forms. The tertiary ulcers may occur in any part of 
the pharynx. They extend rapidly and deeply, perforating the 
pillars of the fauces or the velum (Plate VI) in a few days, and 
gradually eating away the whole velum, uvula, and faucial 
columns, as illustrated by one of my cases in Fig. 157. 

Etiology. — The specific virus of syphilis is yet one of the 



398 DISEASES OF THE EAR, NOSE, AND THROAT. 

unknown quantities in medicine notwithstanding the fact that 
a considerable percentage of humanity are, or have been for 
many generations, infected by it. The occurrence of the pri- 
mary lesion in the mouth or pharynx is generally in conse- 
quence of kissing or of using utensils not thoroughly cleansed 
after having been used by syphilitics. They may also result 
from certain practices of sexual perverts. The secondary stage 
of syphilis is quite generally accompanied by throat lesions, and 
next to the genital organs the throat is the most frequently 
affected. Tertiary manifestations may crop out in the pharynx 
a quarter of a century after the appearance of the initial sore, 
but the average interval is about seven years (" the perfect 
number " %). 

Symptomatology. — The primary lesions of the throat are 
attended with so slight a disturbance that they are altogether 
likely to be overlooked. The submaxillary lymphatic glands 
may be enlarged and tender to the touch. Inspection discloses 
a red, or perhaps a gray, denuded spot with prominent edges. 
It generally disappears spontaneously. As already remarked, 
the initial lesions are mostly found on the tonsil. 

Fournier {Bull. Med., Nos. 9 and 10, 1895) "recognized 
syphilitic ulcer of the tonsil in 40 per cent, of his cases of ulcers 
of the mouth. The sore is generally single, and sometimes 
covers the whole tonsil, occasionally extending to the pillars of 
the fauces and to the base of the tongue. The erosive form is 
the most common. The symptoms are trifling, but the ulcer- 
ative form causes pain and difficult swallowing ; the ulcers are 
brown, gray, or yellow and the tonsil is indurated." Occasion- 
ally there is some systemic disturbance. 

Secondary symptoms manifest themselves as an erythema or 
as mucous patches on one or both sides of the throat. The 
erythematous eruption occurs either in blotches, suggestive of 
the roseola, or it may appear as a diffused redness spreading 
over the whole pharynx. This stage is attended with the usual 
symptoms of simple sore throat. After a few days, distinct 
patches are clearly made out on the anterior columns or on the 
velum and other parts of the throat or mouth. The sides of 



DISEASES OF THE PHARYNX. 399 

the tongue near its base are especially liable to suffer. At first 
these mucous patches appear as slight, rounded elevations of a 
dark- red color. Their centres soften and break down, leaving a 
characteristic, slightly-cup-shaped excavation, which later as- 
sumes a gray color. In this stage swallowing is attended with 
pain. 

The tertiary lesions generally begin by attacking one tonsil 
and the adjacent faucial pillars. The nodular and gummatous 
points begin to show signs of breaking down, then the epithelial 
layer covering them grows thin, revealing a yellow spot under- 
neath. Finally the epithelium is exfoliated, exposing an ulcer- 
ating process which penetrates the mucosa deeply, leaving an 
accentuated cup-shaped depression surrounded by uneven, but 
prominent, ragged edges. These ulcers are rapidly destructive 
to the soft tissues, and do not seem to be retarded in their 
erosive action by cartilage or bone. I have seen them perforate 
the soft palate in a few days, and for a time no treatment would 
stay their progress or appear to produce any impression what- 
ever. The whole soft palate is sometimes destroyed, as I have 
seen in a series of cases (Fig. 157). Cicatricial contractions have 
the effect of narrowing the lumen of the throat, and adhesions 
may encroach seriously upon the upper part of the pharynx or 
even shut it off from the lower part by adhesions of the soft 
palate to the posterior pharyngeal wall (Plate VI) similarly to 
the condition shown in Fig. 156. 

It is somewhat remarkable to observe the trivial character 
of the subjective symptoms as compared with the extensive 
gnawing away of the structures of the throat. I have seen this 
corrosive process plowing through the faucial columns and the 
velum, leaving perforations, eating away their borders until 
several small apertures united into one large hole, destroying 
one of the supporting shreds of the velum, and allowing the 
ragged remnant to drop, and hang as a pendant, swaying and 
fluttering with the currents of air. Patients subject to these 
erosions sometimes appear to experience less inconvenience from 
them than others suffer from a common cold. But in other 
individuals much pain attends the process, and swallowing 



400 DISEASES OF THE EAR, NOSE, AND THROAT. 

causes a distressing effort. Solids must be eschewed and the 
diet confined to liquids until amelioration of the condition can 
be effected. 

Diagnosis. — This disease may be mistaken for tuberculosis, 
and in the early stage may be confounded with a simple catarrhal 
inflammation of the mucous membrane. But the latter yields 
readily to treatment, while the syphilitic disease progresses unin- 
fluenced by any other than specific treatment. 

In tuberculosis serious constitutional disturbances are 
present, such as are not accompaniments of syphilis : fever 
emaciation, etc. The areas of hyperemia that later become the 
seat of ulceration are paler and softer in tuberculosis than in 
syphilis. The ulcers of syphilis have more regular, clearly 
defined borders and are deeper than in tuberculosis. The pain 
of the latter disease, especially in swallowing, causes great 
suffering, while it is not a prominent symptom of syphilis and 
may be absent altogether. The patient improves and gains in 
weight on specific treatment in syphilis, but grows worse in 
tuberculosis. The presence of pulmonary tubercular lesions 
will aid in clearing up the diagnosis. 

Prognosis. — The primary sore disappears in about six 
weeks. The secondary lesion is about that time in coming on 
after infection and lasts approximately the same length of time 
when left to nature. The third stage is far more serious, for, 
while the primary and secondary periods may not menace health 
or life, the tertiary form invades all tissues with a wanton de- 
struction that is, at times, appalling. Important structures are 
not immune. A large blood-vessel may be opened and cause 
a fatal haemorrhage. Contractions of cicatricial tissues may 
constrict the throat and seriously interfere with breathing, 
swallowing, and speaking. 

Treatment. — Cleansing solutions should be used on the 
ulcerating surfaces before local applications will be of any avail. 
For this purpose I have had satisfactory results from the alka- 
line antiseptic solutions of Dobell and Seiler, in the form of a 
coarse spray with sufficient force to the stream to dislodge and 
wash away all the dirty secretions. These are good, cleansing, 






DISEASES OF THE PHARYNX. 401 

soothing sprays for the primary lesions and the erythema also. 
Then I touch the denuded surface with tincture of iodine, pure, 
by means of a small cotton pledget twisted hard upon the silver 
applicator. When the iodized cotton is pressed upon the ulcer- 
ating part, not enough of the tincture should be left to run 
down over the healthy membrane. This treatment is usually 
followed by a drying up of the discharges and the institution of 
a healthy granulating process. 

If the throat is exceedingly painful, especially upon swal- 
lowing, one is justified in painting it with a 4-per-cent. solution 
of cocaine just before meals, to insure sufficient ingestion of food 
to support the strength. After cleansing and drying the ulcers 
with absorbent cotton, I cover them with a coating of aristol by 
means of a small powder-blower (Fig. 32). The antiseptic and 
slightly anaesthetic effects of aristol, besides its power of pro- 
moting granulation formation, have seemed to me to transcend 
the properties of any other single remedy. Sajous cleanses 
with a solution of potassium permanganate, and uses zinc 
sulphate or lead acetate, in a 5-grain solution, for their astrin- 
gent effect, or 5 minims of the tincture of the chloride of iron 
in a drachm of glycerin. Mackenzie used 20 grains of the zinc 
chloride to the ounce for the erythema and tincture of iodine 
for the mucous patches. If the ulcers were indolent he pre- 
ferred copper sulphate, 15 grains to the ounce. In the secondary 
and tertiary periods I employ mercury and potassium iodide, the 
mixed treatment, and tonics, with whatever general treatment 
the condition of each patient suggests. 

Cancer of the Pharynx. 

Synonym. — Carcinoma of the pharynx. 

Pathology. — Cancer of the superior portion of the pharynx 
is generally of the scirrhous form, and presents, in its early 
history, an indurated mass not clearly defined in its circum- 
ference. At first the mucous membrane covering it may not 
show any visible changes. The growth may extend to include 
the soft palate and pharyngeal vault. As the epithelium breaks 
down and ulceration of the surface of the tumor begins, a fetid 

26 



402 DISEASES OF THE EAR, NOSE, AND THROAT. 

exudate bathes the surface, which assumes a red or light- 
greenish appearance. Large, pedunculated granulations are 
sometimes to be seen, during this carious process, springing from 
the floor of the ulcer. The submaxillary lymphatic glands be- 
come infiltrated early in the attack. 

When the cancer is situated in the lower part of the 
pharynx, or the pharyngo-laryngeal cavity, it generally takes on 
the character of epithelioma. Its most usual site is a little 
below the arytenoid cartilage. Instead of the red or light- 
greenish surface of ulcerating scirrhus, this variety presents a 
gray surface inclosed by the very red, tumefied, mucous mem- 
brane. The disease spreads until it circumscribes the passage. 

Etiology. — Heredity is the only known cause of this 
disease. 

Symptomatology. — Inspection reveals the presence of a 
tumor or an ulcerating surface. The symptoms are character- 
istic of a lesion obstructive to respiration and deglutition. Pho- 
nation is interfered with, the speech is thick, and there is a 
foul-smelling, frothy expectoration. Swallowing is painful, but 
the suffering is not limited to this act, being constant and some- 
times extending to the Eustachian tubes and ears. 

Diagnosis. — This is not obscure. It is possible to mistake 
this for a syphilitic lesion, but the use of mercury and potassium 
iodide will remove all doubt. In a case recently under my 
observation the attending physician was not able to reach a 
conclusion. I suggested that a mixed treatment would soon 
result in recovery, which in a few weeks followed, demonstrating 
the specific nature of the lesion. 

Prognosis. — Sooner or later death closes the scene. 

Treatment. — In the nature of the case only palliative meas- 
ures are proper. If death is impending by obstruction to respira- 
tion, intubation or tracheotomy may prolong life. Nourishment 
may be administered by the oesophageal tube or by enemata, 
when swallowing is obstructed. Cocaine, morphine, and seda- 
tive sprays afford temporary relief only. 

Thomas Hubbard reports, in the Journal of the American 
Medical Association, June 13, 1896, a case of squamous epithe- 



DISEASES OF THE PHARYNX. 403 

lioma of the velum palati cured by injections of caustic potash 
by a curved platinum needle. Injections were repeated wherever 
proliferating epithelial growths were seen. Cicatrization was 
rapid as well as the general improvement. The case remained 
cured after two years. 



CHAPTER XXXIV. 

DISEASES OF THE PHARYNX, CONCLUDED. 

Retropharyngeal Abscess. 






Etiology. — Abscess in the posterior pharyngeal wall may 
result from acute inflammation of the pharynx or of the sub- 
mucous tissue and glands ; from a middle-ear suppuration in 
consequence of the pus breaking through the anterior wall of 
the tympanic cavity or through the semicanal for the tensor 
tympani muscle, and from a disease of the vertebrae. It is 
more likely to occur in the strumous or syphilitic, and may be 
a sequel of the eruptive fevers or diphtheria. Traumatism 
resulting from the swallowing of fish-bones, the impact of a 
lead-pencil, etc., or scalding liquids and destructive chemicals 
may give rise to retropharyngeal abscess. 

Symptomatology. — If the abscess is located in the upper 
and back part of the pharynx there is a sensation of fullness 
accompanied by obstruction to nasal respiration with nasal voice. 
The tumor may be seen in this locality with the rhinoscopic 
mirror, and if it is not too high it may become visible by using 
the palate-elevator (Plate VI). On passing the finger into the 
vault of the pharynx it meets with a resistance which may be 
mistaken for adenoid vegetations. When it is posterior to the 
base of the tongue it can be brought into view by the use of 
the tongue-depressor. If the swelling is behind the glottis and 
attains a large size it is liable to press on the epiglottis and 
embarrass its functions. The swallowing of foods and liquids 
is so interfered with as to cause their entrance into the larynx. 
Dyspnoea of such a serious degree as to endanger the patient's 
life may result from an abscess in this region. Occasionally the 
tumefaction increases to such a size as to be visible by means of 
a swelling in the side of the neck. The inflammatory process 
may extend to the cervical glands, producing induration, pain, 
and tenderness. 
(404) 



DISEASES OF THE PHARYNX. 405 

The head assumes a position suggestive of torticollis, being 
held fixedly to one side with the face upturned and everted. 

The general condition is one indicative of a severe illness. 
The temperature is often somewhat elevated, and thirst adds to 
the general discomfort. Like tonsillar abscess, rupture takes 
place usually into the throat. The evacuation of pus may fill 
the larynx and cause strangulation, or, if relief is not obtained 
early enough by incision or rupture, a dangerous or fatal oedema 
of the larynx may occur, or the pus may burrow among the 
cervical muscles and produce an abscess of the neck, or it 
gravitates to the thoracic cavity. 

Inspection shows a bulging of the mucous membrane at 
the seat of the swelling. The tumefaction and the contiguous 
structures present a dark, dusky-red hue, including the uvula 
and soft palate. Fluctuation can be felt by pressure with the 
finger over the bulging surface. 

Diagnosis. — Retropharyngeal abscess may be confounded 
with other inflammatory affections of the throat, but the absence 
of cough, pseudomembrane, vocal changes, and ulcerative con- 
ditions of the mucous membrane, taken together with the pres- 
ence of obstruction to respiration and deglutition, the unnatural 
fixation of the cervical muscles and twisting of the neck, the 
presence of bulging and fluctuation in the walls of the pharynx 
proper are decisive diagnostic features. 

Treatment. — If seen early, the ice-bag (Fig. 78) should be 
applied to discourage pus formation. As soon as fluctuation 
can be made out the abscess should be punctured with bistoury 
or trochar, making an opening sufficient to evacuate the cavity, 
but not large enough to cause a profuse gush of the contents 
to overwhelm the patient by filling the larynx and causing 
strangulation. MacCov recommends that the incision be made 
high enough in the swelling to necessitate pressure on the 
tumor to empty it, so as to avoid too great and continual flow 
of pus. The incision should be so made in a vertical direction 
as to leave a small wound so as not to favor the entrance of 
food into it during the act of swallowing. The internal carotid 
artery must be avoided by cutting toward the median line. 



406 DISEASES OF THE EAR, NOSE, AND THROAT. 

Cocaine should be painted, in a 4-per-cent. solution, over the 
part to be entered, before the operation. A trochar can be used 
instead of a knife, but care is necessary to prevent it suddenly 
plunging beyond the abscess, as the wall yields, and injuring the 
parts beneath. The vertebrae are easily damaged by such an 
accident. The instant the abscess is opened the patient's head 
should be thrown forward to avoid the flowing of pus and blood 
into the larynx. The part of the knife-blade that is not to 
enter the tissues is protected by twisting cotton firmly around it 
as is done on the cotton-carriers. 

The blood is likely to be found impoverished and calling 
for iron and a nutritious diet. Alteratives containing iodine 
and the bitter tonics are useful. The throat should receive 
proper attention until the wound heals, and any abnormality 
present should be corrected. 

Neuroses of the Pharynx. 
There are two varieties of neuroses affecting the pharynx, 
— one of sensation, the other of motion. 

neuroses of sensation. 

These affections are of four kinds : hyperesthesia, anaes- 
thesia, paraesthesia, and neuralgia. 

Hyperesthesia. — The upper portion of the pharynx is 
liable to increased sensitiveness in persons subject to frequently 
recurring attacks of inflammation, and in the hysterical. No 
other abnormality may be discernible in the individual aside 
from the exquisitely sensitive throat. 

Treatment. — If any inflammatory condition appear on ex- 
amination, this must be combated by such remedies as "have 
been mentioned for pharyngitis, etc. If the condition give 
considerable discomfort one may be justified in applying cocaine 
in a 4-per-cent. solution, without the patient's knowledge of 
the nature of the remedy. A 10-per-cent. solution of carbolic 
acid in glycerin obtunds the sensibilities of the nerve-ends, 
and does not present any of the objections applicable to cocaine. 
The membrane can be protected by an emollient and slightly 



DISEASES OF THE PHARYNX. 407 

auaesthetic spray consisting of camphor-menthol in lavolin. It 
is best to begin with a 3-per-cent. solution of this, giving the 
patient directions to use it in an atomizer for home treatment, 
and increase to a 10-per-cent. solution in office treatment, which 
can readily be done if the stronger preparation is employed in 
the dilator, or nebulizer (Figs. 18 and 120), at first, and after- 
ward in a coarser spray (Fig. 116). 

Aristol is preferable to most other powders, for its local 
anaesthetic and adherent qualities. Aconite in glycerin, a salol- 
or antipyrin- spray or guaiacol applications diluted with glyc- 
erin at first, pure afterward, are indicated if a rheumatic or 
gouty condition exist. Added to these, sodium salicylate, sal- 
icin, antipyrin, and lithium are effective in ridding the system 
of the uricacidsemia that may lie at the root of the trouble. 

If the case is of an hysterical nature, sedatives and tonics 
are required : valerian, the bromides, strychnia, arsenic, iron, etc. 

Anaesthesia. — Loss of sensation is of less import than its 
exaltation, since it is not accompanied with like suffering. It 
is sometimes a sequel of diphtheria or insanity. Nerve-tonics, 
such as are mentioned above, and galvanization are indicated. 

Parcesihesia. — Patients sometimes experience the sensation 
as if some foreign body were in the throat, when it is impossible 
to make out either the presence of one or any evidence that one 
may have at any time found lodgment. Indeed, no abnormal 
condition whatever of the pharynx is discernible. This condi- 
tion obtains in hysterical individuals, and it is difficult to satisfy 
them that they are mistaken. This manifestation is purely of a 
neurotic character and must be treated accordingly. 

Treatment. — Such methods as are recommended for hyper- 
sesthesia are appropriate here, — nerve-stimulants, tonics, or seda- 
tives as the particular features of the case may demand. 

Neuralgia. — While painful sensations in the pharynx are 
sometimes attributable to inflamed follicles, uric-acid irritation 
and various local lesions, there is a class of cases in which pain 
is experienced without the presence of any visible morbid process 
to account for it. This occurs in hysteria and is very difficult 
to influence. 



408 DISEASES OF THE EAR, NOSE, AND THROAT. 

Treatment. — If any local lesion can be discovered it must 
be treated according to the principles already laid down, but 
when the pain is purely neurotic, topical applications to the 
sensitive or painful spot, if it can be located, and nervines, 
sedatives, and tonics, as set forth in treating of hyperesthesia, 
must be brought into requisition. 

NEUROSES OF MOTION. 

Two kinds of neuroses of motion are met with : spasms 
and paralysis. 

Spasms. — Spasmodic contractions of the pharyngeal mus- 
cles may be excited by any local irritant : traumatic, such as 
harsh particles of food ; or idiopathic, such as inflamed follicles ; 
or the affection may be purely neurotic, such, for example is 
globus hystericus. The levator palati muscle is occasionally 
subject to choreic attacks, in which the soft palate is thrown 
against the wall of the pharynx with more or less regular con- 
tractions and relaxations, accompanied by objective smacking 
or crackling sounds. These spasms may be associated with 
serious and grave neuroses, as well as with inflammatory con- 
ditions of the soft palate. Central nervous lesions and hydro- 
phobia are characterized by this symptom. 

Treatment. — If pharyngeal spasm can be traced to inflam- 
mation of the velum or oedema of the uvula, the proper treat- 
ment already outlined for these conditions will afford relief. 
Anomalous conditions of the nasal cavity must be searched for, 
and inflamed follicles in the pharynx that might provoke the 
attacks. Any local diseased condition must be corrected. 
When the contractions are dependent upon other maladies the 
treatment must naturally be addressed to the initial affection, 
such as brain-tumors and hydrophobia, for the spasms constitute 
a symptom only of such diseases. Diffusive nerve-stimulants, 
tonics, and hygienic and dietetic measures appropriate to each 
case will be suggested by the conditions present. 

Paralysis of the Pharynx. — Paralysis of the muscles of 
the pharynx results from diphtheria, syphilis, some central 
nervous lesion, or the fatal fevers. All the pharyngeal con- 



DISEASES OF THE PHARYNX. 409 

strictor muscles may be involved or the disease may affect only 
one, or the muscles of one side alone are sometimes involved. 
There may be paralysis of one-half and paresis only of the 
opposite half of the pharynx. 

Swallowing and speech are more or less impaired, according 
to the extent of the paralysis. Food, and especially liquids, 
regurgitate into the posterior nares or enter the larynx. The 
latter accident is the more likely to occur when the epiglottis 
is included in the paralytic condition. 

Treatment. — The therapeutic measures will be determined 
by the nature of the lesion on which the paralysis depends. If 
it is a sequel of diphtheria, strychnia and arsenic are indicated. 
Excellent results have been reported during the past year 
(1896) from the subcutaneous injections of strychnine. In ad- 
dition to tonics I prefer for such conditions a current from the 
primary coil of a faradic battery, which, as the galvanometer 
demonstrates, possesses galvanic properties. This will cause 
contractions of the muscles if the disease has its origin in the 
nervous centres, but in case of atrophy of the muscles they do 
not respond to the current, The condition in the latter case is 
unpromising. In addition to electric treatment three or four 
times a week, general tonic remedies are usually called for. 

Burns and Scalds of the Pharynx. 

The pharynx is the seat of injury from inhaling very hot 
steam, air, or smoke, especially in burning buildings. Firemen 
are particularly subject to these accidents. Children sometimes 
inhale steam from a tea- pot or kettle or pour hot liquids down 
their throats. Patients and nurses by mistake give escharotic 
fluids instead of the correct internal medicine. I have had 
patients whose throats w r ere severely burned by aqua ammonia 
and carbolic acid in strong solutions that were administered by 
mistake from bottles standing beside those containing the proper 
remedies. 

Symptomatology. — Immediately after these accidents the 
mucous membrane of the throat is of a gray color, produced by 



410 DISEASES OF THE EAR, NOSE, AND THROAT. 

the destructive agent. Inflammation follows, with more or less 
suppuration and sloughing of the tissues. 

Diagnosis. — This is usually made by the patient or his 
friends before the arrival of the physician. 

Prognosis. — Persons caught in burning buildings and fire- 
men are often so seriously burned by inhaling heat, hot smoke, 
and sometimes steam that recovery is impossible. There may 
be such an extensive breaking down of the tissues in the throat 
as to leave a stenosis if recovery take place. 

Treatment. — Ice-bags (Fig. 78), cool drinks, or, better still, 
pellets of pure ice in the mouth afford some relief and tend to 
modify the severity of the inflammation. Nourishment may 
have to be given for a time per rectum. When the larynx is 
involved to the extent of impending suffocation, tracheotomy 
must be performed at once. 

Foreign Bodies in the Pharynx. 

It is not uncommon to find fish-bones, pins, needles, and 
bristles, among sharp-pointed articles, lodged in the walls of the 
pharynx. As the constrictor muscles contract about them, they 
are forced into the soft tissues, until in some instances they 
escape detection on first looking into the throat. I have found 
such bodies as sections of juniper-leaves, etc., so imbedded as to 
be extracted with the greatest difficulty. This is especially true 
when they have remained for a number of days in the throat 
exciting continued efforts at swallowing and setting up an 
intense congestion of all the surrounding structures. 

Besides articles of a sharp, piercing nature that penetrate 
the tissues, bodies like unmasticated boluses of food and coins 
occasionally slip into the gullet and threaten strangulation. 

S//mj)tomatoIogg. — Sharp bodies are generally arrested in 
their progress by being caught in the lateral walls of the 
pharynx, where they will be found projecting from the tissues 
which they have penetrated. Small bodies are likely to lodge 
on one side of the epiglottis in the pyriform sinus. The large 
boluses of food, coins, etc., are arrested at a point just posterior 
to the larynx or a little superior to it, and are very liable to 



DISEASES OF THE PHARYNX. 411 

catch upon the epiglottis and force it downward. Little bodies 
often drop into the pyriform sinus or the glosso-epiglottic fossa. 

The symptoms produced by foreign bodies in the throat 
are sometimes very distressing, and even dangerous. If the 
epiglottis is forced downward so as to close the entrance to the 
larynx the patient may suffocate before relief arrives. When 
sharp articles stick in the throat they produce a pricking sensa- 
tion, which increases during the act of swallowing. Pebbles, 
buttons, and the like may remain secreted in the pyriform 
sinuses for a considerable time without giving rise to serious 
inconvenience. 

It often happens that when crusts of bread and other hard 
substances are swallowed they scratch the mucous membrane of 




Fig. 158.— Mackenzie's Lateral Throat-forceps. 

the throat, and this abrasion, giving rise to irritation, produces 
the impression in the mind of the patient that a foreign body is 
present. I have known them to insist strenuously upon the 
presence of some substance ; but an application of a 4-per-cent. 
solution of cocaine to the irritated area removes it apparently. 
There is also a similar sensation due to a point of irritation 
which may be found to exist in an inflamed follicle. 

Certain susceptible individuals occasionally believe they are 
afflicted with a foreign substance in the throat when the trouble 
is purely a nervous one, — globus hystericus. 

Treatment. — Sometimes foreign bodies can be seen by de- 
pressing the tongue, but generally the laryngeal mirror is nec- 
essary. Remembering what has been said about the points of 
lodgment of the various kinds of bodies, and ascertaining, if 



412 DISEASES OF THE EAR, NOSE, AND THROAT. 

possible, from the patient what the object was most likely to 
have been, the search is much facilitated. Sometimes it is best 
to insert the finger to locate the body, and it may be possible to 
extract it during this examination. 

Long, curved forceps are best adapted to this use (Fig. 158). 
One should be careful to not wound the adjacent tissues in the 
effort to grasp the foreign body. 

In extreme cases it may become necessary to open the 
trachea in order that respiration may proceed until the body 
can be rescued. A bolus of food may be forced down into the 
oesophagus if it cannot be extracted. Considerable irritation or 
inflammation follows these accidents. 









PART IV. 



Diseases of the Larynx. 



Plate VII 



PLATE VII. 



ANATOMY OF THE LARYNX. 



a. Thyroid cartilage. 

b, Cricoid cartilage. 

e, Arytenoid cartilage. 

d, Cartilage of Santorini. 

e, Cricothyroid membrane. 
/, Vocal band. 

g, Arytenoidens muscle. 

A, Lateral cricoarytenoid muscle. 

i, Posterior cricoarytenoid muscle. 

j. Epiglottis. 

A;, Vocal process. 



Figs. 1 to 9. 

ra, Cartilage of Wrisberg. 

n, Aryteno-epiglottic fold. 

o 1 , Upper fasciculus of thyro-arytenoid muscle. 

o a , Middle fasciculus of thyro-arytenoid muscle. 

o 3 , Lower fasciculus of thyro-arytenoid muscle. 

p, Ventricle of the larynx. 

q, Laryngeal sac. 

r, Ventricular band. 

s, Superior aryteno-epiglottic muscle. 

t, P, Two fasciculi of thyrocricoid muscle. 

u, Superior thyro-arytenoid ligament. 



Fig. 1. 

posterior view. 



ABDUCTION AND ADDUCTION. 
Fig. 2. 



Vocal bands abducted by 
contraction of posterior crico- 
arytenoids (arytenoideus cut 
off). 

Fig. 4. 



LATERAL, VIEW. 

Section of larynx showing 
the relation of adductor and 
abductor muscles. 



Fig. 3. 
posterior view. 
Vocal bands adducted par- 
tially by contraction of lateral 
cricoarytenoids (arytenoi- 
deus not having acted) . 

Fig. 5. 



HORIZONTAL SECTION OF LARYNGEAL FRAME-WORK, ABOVE VOCAL BANDS. 

Vocal bands in abduction. Vocal bands in partial adduction. 



EXTENSION AND RELAXATION. 



Fig. 6. 
lateral section. 
Relaxation of vocal band 
through contraction of thyro- 
arytenoids and relaxation of 
thyrocricoids. 



Fig. 7. 

lateral section. 

Interior of larynx. Flaps 

raised to show laryngeal sac, 

and the relation of muscles 

with the mucous membrane. 

Fig. 9. 
anterior section. 
Interior of larynx and rela- 
tion of muscles. 



Fig. 8. 
lateral section. 
Extension of vocal band by 
elevation of the cricoid carti- 
lage through contraction of 
the thyrocricoid muscles and 
relaxation of the thyroaryt- 
enoids. 



Fig. 10. 

innervation of the larynx. 

Posterior section of neck and upper part of chest, showing 

the course of the pneumogastric nerves, their branches, and 

their relations. Lateral half of trachea and quarter of larynx 

cut off. 



A 1 , Pneumogastric nerve. 

JB l , Superior laryngeal. 

Right recurrent laryngeal. 

Right lung. 

Left recurrent laryngeal. 

Branch of superior laryn- 
geal. 

(Esophagus. 

Aorta. 

Pulmonary artery. 

Trachea. 

(upper), Internal jugular 
vein cut off. 

(lower), Bronchi. 

Arytenoid cartilage. 

Subclavian artery. 

Common carotid "artery. 

External carotid artery. 

Internal carotid artery. 

Base of cranium. 

(upper), First cervical 
vertebra. 

(lower), Arytenoideus 
muscle. 

Pharynx cut oil' from up- 
per attachments. 

p:piglottis. 

BLyoid bone. 

Thyroid cartilage. 

Cricoid cartilage. 



s, Thyroid gland. 
u, Thyrocricoid muscle. 
v, Cervical vertebrae. 
x, y, Muscles of neck. 
z, Innominate artery. 



Fig. 11. 

arteries and veins of 
the anterior portion 
of the neck. 
Vessels of the neck, show- 
ing those in danger of being- 
severed in making artificial 
opening into the larynx and 
trachea, and their connec- 
tions. 

a, Trachea. 

b, Cricoid cartilage. 

c, Thyroid cartilage. 

d, Thyroid gland. 

e, Cricothyroid membrane. 
/, Thyrohyoid membrane. 
g, Hyoid bone. 

h, Aorta. 

i, Innominate artery. 

j, Common carotid artery. 

k, Superior thyroid artery. 

I, Anterior jugular vein. 

m, Cricothyroid artery. 

n, Internal jugular vein. 

o, Thyroid plexus. 

p, Right inferior jugular 

vein. 
q, Left inferior jugular vein. 
r, Cricothyroid vein, 
s, Superior thyroid vein. 
t, Middle thyroid vein. 
w, External jugular vein. 
v, Subclavian vein. 
x, Right and left innominate 

vein. 
y, Superior vena cava. 



Plate ¥11 




E. Sajous, Pinx.it. 



Burl< & M c Fetndge. Lith. Phila 



CHAPTER XXXV. 
DISEASES OF THE LARYNX. 

Laryngoscopy and Instruments. 

Examination of the interior of the larynx, commonly 
tiled laryngoscopy, is made by means of a light reflected into 
Le larynx through the medium of two mirrors. The first, or 
forehead-, mirror is illustrated in Fig. 4, and is used in the same 
manner as in otoscopy and rhinoscopy, already described. The 
second mirror, sometimes dignified by the name of laryngo- 
scope, consists of a circular plane-glass mirror inclosed in a 
metallic frame, to which is attached a wire handle set at an 
angle of 120 degrees to the plane of the mirror (Fig. 112). It 
is made in several sizes, but those most commonly employed 
vary from one inch (twenty-five millimetres) to one-half inch 
(twelve millimetres) in diameter. The most perfect view is ob- 
tained by using as large a mirror as the proportions of the 
throat will permit without contact between mirror and mucous 
membrane. The sizes are numbered according to their diame- 
ters, No. 1 being one inch (twenty-five millimetres) wide, and 
the others graded by one-eighth-inch (three millimetres) varia- 
tions down to one-half inch (twelve millimetres), and numbered 
accordingly. In the capacious throats of adults the largest size 
is to be used, while in children the smaller ones are necessary. 

For the purposes of illumination there are various devices 
for projecting the rays of light upon the laryngeal mirror. Fig. 
159 shows an ingenious device of Allen DeVilbiss, which is a 
modification of Mackenzie's light-concentrator. It is simpler in 
construction than Tobold's apparatus, although it is similar to 
it. It is provided with two mirrors, one plain and the other 
concave, both of which are attached to a stationary mirror-bar 
by means of ball-and-socket joints, so arranged that they may 
be easily changed to any position on the bar and inclined at any 
angle. 

(415) 



416 



DISEASES OF THE EAR, NOSE, AND THROAT. 



The plane mirror enables the physician to show his patient 
the condition of the affected parts, and, if needing treatment, 
explain its necessity. "By this method patients may see the 
extent and nature of their diseases and receive treatment when 
they might otherwise consider it of but little importance, nol 
demanding medical assistance." If deemed advisable, the pa- 
tient may be shown, from time to time, the changing condition 
of his disease, and thus be kept interested in its treatment. By 



this device the patient can see to keep himself " in light," thus 




Fig. 159.— DeVilbiss Illumikatok. 



relieving the physician from the necessity of frequently adjust- 
ing the mirror. This laryngoscope can be adjusted to a student's 
lamp, and may be raised or lowered by means of a single 
set-screw. Figs. 1, 2, and 5 show other adjustable lamps. 

Assuming that we have proper illumination, the examina- 
tion proceeds as follows: The patient and examiner being in 
the relative positions illustrated in Fig. 159, with the patient's 
mouth open, the tip of his tongue is taken between the phy- 
sician's thumb and index finger, protected from actual contact 
with the tongue by a napkin or thin towel, and the tongue is 



DISEASES OF THE LARYNX. 417 

held protruded from the mouth. The patient should not make 
an effort to force the tongue forward nor to retract it, but should 
let it lie passively in the surgeon's control. This is necessary 
in order to raise the epiglottis and expose the aperture of the 
larynx. This is effected by traction on the glosso-epiglottic 
ligament, which happens in the drawing forward of the tongue. 
Unless the examiner is careful in this act he will wound the 
fraenum on the sharp edges of the lower incisor teeth. It is 
advantageous to instruct the patient to assist in his examination 
by holding his tongue himself, using the hand opposite to the 
one used by the examiner, so as not to be in the way of the 
laryngeal mirror as it is introduced. 

The light is now focused on the uvula, and the front of 
the laryngeal mirror is exposed for only an instant over the 
flame to warm it. This must be done in order to prevent the 
moisture of the breath from condensing upon the glass and 
blurring the laryngeal image. After a second of warming the 
mirror is touched to the surgeon's cheek, or a sensitive part of 
his hand, to determine if the heat is sufficient to avoid conden- 
sation. If the flame is very hot, or if the mirror is exposed to 
it during too long an interval, the silver, or other backing of 
the glass, is fused, and the instrument destroyed. Glass being 
a poor conductor of heat, there is less danger of melting the 
coating of the back if the glass itself is held next the source of 
heat. 

The laryngeal mirror now being ready for introduction, it 
is held like a pencil, and without loss of time, which would al- 
low the mirror to cool, it is carried into the throat in such a 
way as to avoid contact with the tongue and surrounding parts, 
so as not to cause nausea and retching. The back of the mirror 
is made to impinge upon the anterior surface of the uvula and 
to carry the latter upward and backward. The mirror is then 
turned so as to reflect the rays of light from the forehead-mirror 
into the cavity of the larynx, when an image of the interior of 
the larynx and the superior portion of the trachea will come 
into view. The patient should be told that no pain will be 
caused, and that he should remain perfectly passive and breathe 



•±18 DISEASES OF THE EAR, NOSE, AND THROAT. 

quietly. If he is able to accommodate himself to the situation, 
an opportunity is given to study the vocal cords, which are seen 
in an abducted relation, of a white color, about three-fourths 
of an inch (two centimetres) long, and diverging from the upper 
to the lower ends, as seen in the reflected image. 

If the subject is caused to utter the broad, open sound 
represented by the syllable " ah," as used by vocalists in devel- 
oping their voices, the vocal bands approximate each other and 
become parallel, with only a narrow slit preventing contact be- 
tween them. As seen before vocalization, the vocal bands are 
concealed largely from view by the ventricular bands, only their 
borders being then visible. 

One should not forget that he is not looking directly at the 
contents of the larynx, but at an image of them in a mirror, 
which, of course, reverses the picture to the observer; or, in 
other words, the examiner sees the picture as he would if his 
eye were behind and above the larynx, — the position occupied 
by the mirror. The epiglottis appears in the upper section of 
the mirror as a yellowish-pink valve, showing on its surface a 
map of minute blood-vessels. Its outline is suggestive of a 
Cupid's bow, with the convex surface directed upward. Just 
below this bow is seen the anterior commissure of the vocal 
cords, which is narrower than the posterior commissure, as 
shown in the lower part of the image. The right vocal band 
appears in the left field of the image and the left is reflected in 
the right side of the picture. From the right and left termini 
of the bow-shaped borders of the epiglottis spring the aryepi- 
glottic folds, curving gracefully inward to meet each other in 
the form of a horseshoe, and completing the superior boundary 
of the opening into the larynx by their union in the arytenoid 
commissure (Plate VIII). On either side of the junction of 
the ary epiglottic folds is a nodular eminence called the cartilage 
of Santorini, and immediately to the outside of these knobs, on 
either side and slightly elevated above them, is a bulbous-appear- 
ing prominence, — the cartilage of Wrisberg. These eminences 
are more of a redder hue than the epiglottis. Below them are 
seen the ventricular bands, which spring from an area corre- 



DISEASES OF THE LARYNX. 419 

sponding to the junction of the cartilages of Santorini and 
Wrisberg. 

The junction of the ventricular bands in front, their an- 
terior commissure, is concealed by an eminence, — the cushion of 
the epiglottis. The vocal bands or cords appear below the ven- 
tricular bands, extending from below the cushion of the epiglot- 
tis to points just inferior to the cartilages of Santorini. Between 
the ventricular band and vocal cord is a dark aperture termed 
the ventricle of the larynx. Beyond all these structures appear 
the rings of the trachea. From three to six are usually in 
sight, and sometimes a view of the whole length of the trachea 
to the branch of the right bronchus is obtained. For the 
anatomy of the larynx see Plate VII. 

Difficulties of Laryngoscopy. 

Laryngoscopic examinations are not without considerable 
obstacles in many instances. Although there are individuals 
with capacious throats devoid of sensitiveness, who readily co- 
operate so as to afford a broad-gauge view of the interior of the 
larynx and trachea, there are far more frequently persons who 
have little or no control of their muscles, and who retch and 
gag, and even vomit, when an attempt is made at laryngoscopy. 
In such cases it may become necessary to inure the throat to 
the presence of foreign bodies by the practice, on the part of the 
patient, of inserting smooth, blunt articles, such as spoon-handles 
and the like, daily at home. In this manner a tolerance of in- 
struments may be cultivated to such a degree as to render 
successful subsequent attempts at an examination. 

When repeated efforts fail on account of hypersensitiveness 
of the throat, it is necessary to bring to our aid a 4-per-cent. 
solution of cocaine. This is painted over the base of the tongue 
and the soft palate, and in a few minutes the sensibilities of the 
nerves are so benumbed as to permit of a thorough inspection 
with the mirror. 

Another instance in which it may become necessary to em- 
ploy cocaine is when the epiglottis is pendent to the degree of 
obstructing the rays of light and preventing their penetrating 



420 DISEASES OF THE EAR, NOSE, AND THROAT. 

the laryngeal cavity. In this condition the epiglottis must be 
raised and pressed forward out of the field of vision by a 
curved probe ; but in order to do so without producing pain and 
gagging the epiglottis must be treated to the cocaine solution. 

The tongue is often forced upward and shuts off the view 
if the mirror come in contact with it and produce gagging. 
The patient is told not to strain, and the tongue is not drawn 
forcibly forward. If then the arching of the tongue does not 
recede, the tongue-depressor must be employed. If the mirror 
is held by the right hand, the tongue-depressor is held by the 
left in such a way that the instrument intervenes between the 
thumb and the tongue and the first finger rests under the tip 
of the tongue. The depressor must not be carried far enough 
backward to provoke nausea and retching. 

When the tonsils are enlarged they so encroach upon the 
lumen of the cavity as to interfere with a satisfactory laryngo- 
scopy. A small mirror must be resorted to ; but tonsils sufficiently 
hypertrophied to embarrass an examination of the larynx ought 
to be clipped. 



CHAPTER XXXVI. 

DISEASES OF THE LARYNX, CONTINUED. 

Acute Laryngitis. 

Synonyms. — Acute catarrh of the larynx; spurious croup. 

Pathology. — Acute inflammation of the mucous membrane 
lining the laryngeal cavity is characterized by an engorgement 
of the blood-vessels, — an hyperemia, — accompanied, at first, by 
dryness of the membrane and afterward by an exudation of 
serum upon the mucosa, mixed with undeveloped epithelial 
cells and white corpuscles. The thin, translucent secretion 
soon gives place to a more copious secretion of a thick, opales- 
cent, mucoid character, studded with desquamated epithelium, 
pus-corpuscles, and traces of blood. Points of denudation of 
the mucous membrane are generally present, but the submucosa 
is rarely invaded by ulceration in this affection. 

Etiology. — Exposure to cold is the most common cause of 
this inflammation. Sudden changes from warm, ill- ventilated 
apartments to a cold, damp, or windy atmosphere when the 
subject is in a perspiration or insufficiently clad are frequently 
followed by laryngitis. This is most commonly seen during the 
changes of the seasons from fall to winter and from winter to 
spring. The inhalation of irritating gases such as are often 
generated in laboratories may excite a catarrhal condition of 
the larynx. Dust of certain kinds is a causative factor. Per- 
sons riding over the alkali deserts or plains of the western part 
of the United States are sufferers from rhinitis, laryngitis, and 
conjunctivitis occasioned by the irritating effects of the great 
quantities of alkali-dust in those regions. Overtaxing the 
voice and its improper use by singers and speakers bring on an 
acute laryngitis. Instances of this affection are very common 
during the political campaigns, when stump-speakers are driven 
from the field by the inordinate use of their vocal organs. Fire- 
men — who shout in the heat and smoke of burning buildings, 

(421) 



422 DISEASES OF THE EAR, NOSE, AND THROAT. 

and who often inhale much of the hot air, steam, and smoke — 
are subject to this disease. The uric-acid diathesis, rheumatic 
and gouty conditions, and the eruptive diseases stand in a 
causative relation to acute laryngitis. 

Symptomatology. — The premonitory symptoms of acute 
laryngitis may be so vague and trivial as to scarcely arrest the 
attention of the subject. A slight feeling of dryness, as though 
the air inhaled was devoid of moisture and, therefore, irritating, 
is generally the first unusual condition noticed. This is likely 
to be followed by a scratching or tickling sensation that excites 
efforts to relieve it by clearing the throat or coughing, which, 
instead of relieving the irritation, only adds to the feeling of 
roughness. A sense of constriction or of soreness soon follows, 
but palpation of the larynx seldom develops tenderness. As 
the attack progresses and the vocal cords become involved, 
there occurs a change in the quality, or timbre, of the voice. It 
takes on a husky, or hoarse, character, which has the effect of 
apparently lowering its pitch. About this time discomfort in 
swallowing occurs, amounting to a very painful effort. This is 
especially the case in the rheumatic form of the disease, and 
with the accentuated painfullness of deglutition may come a 
complete loss of voice, so that the only speech possible to the 
patient is a forced whisper. Cough is not necessarily a symp- 
tom of acute laryngitis, but is frequently present. Its hoarse 
character is indicative of the situation of the causative lesion in 
the larynx. Auscultation of the larynx will result in demon- 
strating the presence of mucous rales. These are not heard 
during the initiatory stage, in which the mucous membrane is 
dryer than it is in the normal state ; but later, as the serous 
exudate and mucus bathe the walls of the larynx, the passage 
of air through these fluids gives rise to easily-detected rales. 
The expectoration is characterized by the presence of the secre- 
tions just mentioned, and later in the disease by the presence 
of pus, possibly streaked with blood. The presence of blood, 
however, is generally an accidental and unusual feature, being 
the result of a very violent fit of coughing or, perhaps, of 
vomiting. 



DISEASES OF THE LARYNX. 423 

This disease does not usually give rise to very serious gen- 
eral disturbances of the system in adults, but it often presents 
alarming symptoms in children. As all diseases produce a 
more profound impression during the early years of life than in 
adults, so acute laryngitis may evoke such violent symptoms as 
to fill the patient and friends with terror. The temperature 
rises ; the pulse becomes accelerated, bounding, and hard, and 
the tongue is heavily coated. Even when the little patient 
appears during the day to have no serious sickness, he may 
awaken at night with a suffocative attack out of all proportion 
to the apparent cause. The respiration is embarrassed and the 
respiratory effort is marked by an audible, stridulous sound. 
The cough reveals a changed voice, hoarse and husky, and the 
diminished oxygenation of the blood and the frantic efforts to 
overcome the obstruction to breathing bring on a swollen and 
congested appearance of the face. These attacks are sometimes 
called stridulous laryngitis, and they are probably occasioned by 
the drying of accumulated discharges in the glottis. The child 
breathes through his open mouth, with the result that the air 
entering the larynx and lungs is not moistened by the secretions 
of the nose, as it is in normal respiration. Consequently the 
dry air causes rapid evaporation of the water of the laryngeal 
secretions, with the effect of causing them to dry upon the 
vocal cords until they offer a positive obstacle to the current of 
inspired air. When the obstruction has existed long enough to 
cause actual distress the patient awakens in a frightful state of 
impending strangulation. Soon, however, the active efforts of 
the patient to dislodge the inspissated secretions relieve the 
stenosis and restore free respiration, when calm succeeds the 
storm. The attacks described here have been attributed by 
some authors to a spasm of the adductors of the vocal bands. 
This spasmodic contraction may play a role as a complication, 
but the mechanical explanation is reasonable ; all the elements 
requisite to the production of such attacks are present ; and it 
so conforms to our experience with similar conditions in other 
situations as not to necessitate an exercise of the imagination to 
account for all the phenomena observed. 



424 DISEASES OF THE EAR, NOSE, AND THROAT. 

Inspection of the larynx during an attack of acute inflam- 
mation reveals a mucous lining of a bright-red color (Plate VIII). 
The congested condition may be limited to various portions of 
the membrane, but usually it is diffused over the whole surface. 
There is a tumefied condition in severe forms of inflammation, 
and the ventricular bands may be so swollen as to override the 
true vocal bands and nearly occlude them from view. Then 
they are seen as slight, reddened lines below the ventricular 
bands. Ulcerations are not frequently seen, but small spots of 
the membrane denuded of its epithelium may be present. The 
epiglottis may participate in the inflammation, as shown in Plate 
VIII, or it may not be involved. 

(Edema occurring in the course of laryngitis constitutes a 
grave complication, since it may give rise to fatal stenosis. 

Diagnosis. — In adults no serious difficulty to a diagnosis 
presents, in view of all the symptoms related. It is not likely 
to be confounded with diphtheria except in children, when it 
may be mistaken for true croup. In case of doubt, an exam- 
ination of the fauces will likely reveal false membrane if diph- 
theria is present. A laryngoscopic examination should be had 
if obtainable. The secretions should be subjected to bacterio- 
logical examinations if there is reason to suspect diphtheria. 
However, this disease does not run such a course as does diph- 
theria and it is not attended with the symptoms of profound 
sickness comparable to those of diphtheria. 

Prognosis. — This disease is of short duration and yields 
readily to proper treatment. 

Treatment. — Local remedies are useful as detergents, astrin- 
gents, anaesthetics, protectives, and tonics. A spray of a mild 
alkaline solution with antiseptic properties, such as Seller's, will 
dissolve and wash away the discharges, and, besides leaving the 
mucous membrane clear and free for the application of other 
medicaments, the effect is a very agreeable and soothing one. 
In the dry stage I have found menthol very efficient when in- 
haled in several different ways. If no atomizer is at hand, the 
crystals can be fused in a teaspoon over a lamp or stove until 
the atmosphere of a small room is comfortably impregnated 



DISEASES OF THE LARYNX. 425 

with the volatile fumes. The patient is directed to keep his 
eyes closed to prevent any smarting, and, unless his nostrils par- 
ticipate in the inflammation, he is instructed to breathe through 
the mouth. The inhalation starts a refreshing flow of mucus 
to bathe the parched membrane of the dry stage. Another 
excellent treatment consists in putting 10 drops of pure cam- 
phor-menthol into a half-pint of hot water contained in a tea- 
pot or kettle, wrapping a napkin around the nozzle to prevent 
burning the lips, and then inhaling this medicated steam through 
the mouth with the lips embracing the protected tube. The 
hot, moist steam has an excellent effect, in addition to the action 
of the camphor-menthol in contracting the capillary blood- 
vessels and producing a slightly anaesthetic and antiseptic 
effect. 

Cocaine and silver nitrate are recommended by some writers 
and are used much oftener than they ought to be. They are to 
be avoided in acute laryngitis. 

I have found my throat-tablets useful, and they can be 
given freely, without producing any unpleasant consequences, 
except, perhaps, nausea. Each tablet contains 2 grains of 
ammonium chloride and 5 minims each of paregoric, compound 
syrup of squills, and syrup of Tolu, with 2J grains of extract 
of licorice. These are held in the mouth and allowed to dis- 
solve slowly and trickle down the throat. Besides the desirable 
action of the ingredients of this tablet on the mucous mem- 
brane of the throat, the licorice generally produces a laxative 
effect on the bowels. J. D. Arnold recommends, in the case of 
superficial erosions, the use of cocaine, followed by painting the 
laryngeal mucous membrane with a 1- or 2-per-cent. solution of 
chromic acid. He employs the cocaine not for the purpose of 
anaesthesia, for this strength of chromic-acid solution is not 
painful, but to contract and deplete the blood-vessels, in which 
condition the action of the acid is more beneficial. 

If the inflammation is of a severe grade, the ice-bag (Fig. 
78) is indicated. Leeches to the neck are sometimes employed, 
but cold is preferable. 

General treatment consists, first, in putting the patient in 



426 DISEASES OF THE EAR, NOSE, AND THROAT. 

such a condition as is favorable to successful treatment. He 
need not necessarily be put to bed, but lie had best remain 
in-doors for a few days, where the temperature is uniform and 
where he will not be exposed to those conditions that brought 
on the attack. In the dry, or first, stage, -J- or even J grain of 
pilocarpine is useful to stimulate the sudoriferous and salivary 
glands to activity. This is a substitute for the old-fashioned, 
dismal sweats that loom up in our memory of boyhood. Quinine 
— that much-abused remedy, given for almost every ill that 
afflicts our race — is of little or no use here, as far as my expe- 
rience goes. One or two doses of morphia, ^ grain, combined 
with atropia, g^ 7 grain, and caffeine, ^ grain, have often ap- 
peared to greatly ameliorate, and even shorten, the attacks 
materially. Irritants — tobacco-smoke, alcoholic liquors, etc. — 
must be forbidden. 

If cedema be found, the tissues affected must be scarified, 
to let out the contents. Should the tumefaction and stenosis be 
so great as to seriously embarrass respiration or threaten suffoca- 
tion, tracheotomy must be performed. 

The rheumatic type of acute laryngitis is attended with 
considerable pain and difficult deglutition, that require promptly- 
acting remedies. Ten-grain doses of salicylate of sodium every 
two hours should be given until either the symptoms begin to 
show signs of relief or the physiological action of the drug 
begins to manifest itself in stuffiness in the ears, diminished 
hearing, ringing noises in the ears, or gastric disturbances. 
Then the doses should be placed at greater intervals or discon- 
tinued until these transitory symptoms abate, and renewed again 
in smaller doses until after complete recovery. A fresh prepara- 
tion should always be made, like the formula given in the article 
on the treatment of rheumatic pharyngitis. If the sodium 
salicylate disagree with the stomach or produce serious aural 
symptoms, and more especially if the patieiit already has an 
affection of the ear, the salicin should be substituted for the 
salicylate. I have seen 10 grains of salicin, taken every two 
hours, produce prompt relief before the expiration of a day. 
This effect is hastened if the same doses of effervescing citrate 






DISEASES OF THE LARYXX. 427 

of lithia are taken three or four times a day. Antipyrin is often 
beneficial in this disease. 

Climate has a definite effect on the rheumatic form of 
laryngitis. I have known a patient suffering from it during a 
season of cold, humid, windy weather that prevailed along the 
Great Lakes Region, to go south, into a genial, warm, sunshiny 
climate, and recover from the attack, without medicine, after 
two days of life in the sunshine, so magic in their effects are 
climatic conditions. 



CHAPTER XXXVII. 
DISEASES OF THE LARYNX, CONTINUED. 

Croup. 



^m- 



Synonyms. — Pseudomembranous croup; idiopathic mem- 
branous croup. 

Pathology. — The question of the identity or duality of 
croup and diphtheria is still a mooted one. Excellent author- 
ities differ on this subject. So scholarly an author as Sir Mor- 
ell Mackenzie believed the two to be identical. Both diseases 
affect the mucous membrane, with the result of producing a 
false membrane. Both diseases attack the same organ, — i.e., 
the larynx. Both obstruct respiration. In these three particu- 
lars there is a close similarity in the two diseases, but the 
author is not prepared to admit their identity. Croup is pri- 
marily an affection of the larynx ; diphtheria is generally at 
first an affection of the pharynx, although it may, in a certain 
percentage of cases, develop primarily in the larynx. " In one 
hundred and fifty-one diphtheric cases the membrane was lim- 
ited to the larynx only once. In eighty-eight the membrane 
appeared first in the larynx or simultaneously with that of the 
pharynx " (Northrup). Croup is more frequent in the country, 
while diphtheria is more prevalent in cities. 

In the opinion of the author, the wide difference between 
the unicists and dualists can be harmonized by recognizing what 
certainly appears to be pathologically and clinically true : that 
there are two varieties of membranous croup, the one diphtheric, 
the other non-diphtheric. " Out of two hundred and eighty-six 
cases of membranous croup 80 per cent, were diphtheric and 
14 per cent, were certainly not diphtheric" {Medical Record, 
September 15, 1894). 

True croup is an idiopathic disease ; diphtheria does not 
arise spontaneously, independently, in isolated instances without 
inoculation or infection, directly or indirectly, from a previously 
(428) 



DISEASES OF THE LARYNX. 429 

existing case of the disease, as croup does. The latter is not a 
contagious, inoculable disease ; diphtheria is pre-eminently so. 
Croup does not infect the whole system with a profoundly- 
depressing and exhausting poison, causing paralytic sequels, as 
the diphtheria toxin evolved by the Klebs-Loffler bacillus does. 
The clinical pictures of the two diseases are similar in their 
mechanical effects upon the respiration and consequent deoxy- 
genation of the blood, but from that point their histories are 
not parallel. Their divergencies are apparent to one who has 
had much experience in their treatment. He must recognize 
that we have a laryngeal diphtheria, on the one hand, and a 
true croup, on the other. 

This is a disease of childhood, and occurs most frequently 
about the second year, and from that to the tenth year. 

Croup is an inflammation of the mucous membrane, mostly 
confined to that part of the larynx superior to the vocal bands, 
but it may extend to the trachea. It is attended with the 
formation of an exudate, or inflammatory lymph, that is de- 
posited in the form of a fibrinous membrane on the epiglottis, 
the ventricular bands, and to a greater or less extent upon the 
vocal cords. This false membrane does not penetrate the epithe- 
lial layer to the submucosa as the diphtheric membrane does, 
but it can be peeled off without tearing the mucous membrane 
or leaving a rough, raw, and bleeding or ulcerating surface. 
If the inflammation extend to the submucosa the laryngeal 
muscles become involved, resulting in spasms or paralysis. 

Etiology. — This disease may arise primarily, without any 
discoverable exciting cause, or it may occasionally be secondary 
to injuries, various irritants, scarlet fever, measles, small-pox, etc. 
Cold and moisture, especially combined with strong winds, may 
give rise to attacks. I have not observed that the previous 
condition of health exerted much influence for or against the 
production of croup. Healthy-appearing children seemed to be 
as easily subject to it as those who were badly nourished. The 
author has had a considerable opportunity to study these 
subjects in his practice in connection with the children's de- 
partments of the South-Side and of the West-Side Free Dis- 



•430 DISEASES OF THE EAR, NOSE, AND THROAT. 

pensaries, and, while the children that most easily succumbed to 
diphtheria and other diseases were the feeble and strumous, he 
has seen the fat and rosy children as often attacked by croup as 
those with impoverished systems. 

The chilling of children by exposing them to draughts of 
cold air ; the unpardonable practice of leaving their thighs bare 
and exposed to cold, as is the almost universal custom ; the 
carrying or wheeling of infants bare-headed in the cold ; allow- 
ing children improperly clad to sit about in the open air in 
chilly weather, and to run about the house morning and night 
in their bare feet in cold weather, and similar practices that 
encourage the shocking of the skin by cold and disturbing the 
balance in the circulation of the blood are all prolific causes of 
croup. 

Symptomatology. — The first thing that may be noticed is 
the hoarseness of the child's voice. Before any fever or sub- 
jective symptoms develop the parents may notice the sudden 
change in quality of the voice, but some indisposition may show 
for several days before the attack. Next, a slight cough ap- 
pears that accentuates the coarse timbre of the voice. Its pitch 
sounds much lower than normal. Soon there are signs of fever 
and complaints of not feeling well. If the little one is old 
enough to describe sensations, headache may be spoken of. 

The symptoms often develop with surprising suddenness. 
The child may appear well during the afternoon, and by 7 
o'clock in the evening the voice changes to a hoarse quality, 
which may be overlooked by the untutored or careless, until, 
two or three hours later, coughing and difficulty of breathing 
alarm them to the point of summoning medical assistance. 
With each inspiration now is heard the well-known crowing 
sound of croup. The temperature rises to about 103° F. as the 
night wears wearily on and the obstruction to respiration in- 
creases with the increasing false membrane. The true inflam- 
matory character of the disease is apparent. The pulse is 
accelerated, bounding, and hard; the tongue coated; the skin 
hot and dry ; the face red and puffed ; and the secretions are 
checked. Unless relief is obtained by expulsion of some of the 



DISEASES OF THE LARYNX. 431 

obstructing membrane the difficulty of breathing increases until 
the labor necessitated in aerating the lungs is pitiful in the 
extreme. The sound of the prolonged crowing inspiration and 
the lengthened expiration indicate the extreme narrowing of the 
chink between the vocal bands. As the blood becomes poisoned 
by the lack of oxygen the little one's face, flushed at first with 
a beauteous glow, takes on a bluish tinge that darkens as the 
world grows dark to the little sufferer, until, at last, a cyanotic 
hue announces the approach of death. 

If portions of the false membrane are expelled, more or 
less relief is obtained, and a respite experienced until more mem- 
brane is formed to take its place, when dyspnoea again ensues. 
Often the worst is over in twenty-four or forty-eight hours, but 
in other cases the duration may be five or six days. 

Diagnosis. — Membranous croup may be mistaken for laryn- 
geal diphtheria, acute laryngitis, or laryngismus stridulus. 

It may be difficult sometimes to distinguish croup from 
diphtheria. In croup the constitutional disturbance is less pro- 
found than in diphtheria. Obstruction to breathing is really 
the principal symptom of croup. Slight catarrhal symptoms 
and indisposition may exist for several days before the attack of 
croup, but the diphtheric attack is sudden and accompanied 
with severer symptoms. Croup is neither infectious nor con- 
tagious ; diphtheria is both. In nearly every case of diphtheria 
there is a false membrane in the pharynx, but this is not true of 
croup. The difficult breathing of croup appears suddenly, 
while that of diphtheria is more gradual and lacks the spasm of 
croup. No other member of the family or community catches 
croup ; diphtheria spreads to others, and has paralysis as a 
sequel, while croup has not. In case of doubt a bacteriological 
examination should be made. 

Acute laryngitis resembles croup in some respects, but it is 
'attended by more pain in the larynx, less difficulty in respiration, 
and by no formation of false membrane. Croup is a disease of 
childhood, while laryngitis is generally confined to later years. 
The peculiar crowing sound of croup does not occur in laryn- 
gitis. The cough of the two diseases differs, that of croup 



•132 DISEASES OF THE EAR, NOSE, AND THROAT. 

having a deeper hoarseness and not being so short and hacking 
as in laryngitis. 

Laryngismus stridulus does not present the symptoms of 
sickness like croup. There is no fever and the labored respi- 
ration comes on quickly and subsides in a few minutes. The 
voice remains normal between the attacks. 

Prognosis. — Membranous croup is a very fatal disease. 
Statistics show that considerably more than half of the cases die, 
— 60 or 70 per cent. Since the introduction of intubation of 
the larynx by O'Dwyer the death-rate has materially improved. 
In a collective investigation by Ranke (MilncJiener med. Woch., 
No. 44, 1893), concerning intubation in Germany, he reports 
1445 cases intubated for croup, with 553 recoveries, or 38 per 
cent. 

O'Dwyer (New York Medical Journal, March 10, 1894) 
claims that the " mortality of laryngeal diphtheria without treat- 
ment is 90 per cent., which can be reduced to from 27 per cent, 
to 47 per cent." 

Attacks of great severity may progress rapidly to a fatal 
termination, the end being induced by a spasm of the glottis 
occurring in a few hours from the seizure. In others the 
larynx gradually fills with the false membrane, depriving the 
lungs of air until carbonic-acid poisoning, coma, and death occur. 

Treatment. — A patient with croup should be kept in a 
moist atmosphere. I have made it a rule to put the child in a 
room containing a stove, when it is possible. Then, large vessels, 
like dish-pans or boilers, should be placed on the stove and just 
enough water poured in them to cover their bottoms and keep 
them from burning. A hot fire is kept up and in this way the 
atmosphere of the room is maintained saturated with steam, 
and at a temperature of 76° or 80° F. If there is paper on the 
walls, it will, of course, be spoiled. 

Unslaked lime is sent for, a bushel or more. A lump as 
large as a man's head is placed in a wooden bucket containing 
about two quarts of hot water. As chemical combination takes 
place an abundance of steam is generated which is conducted to 
the patient's head by a tent-shaped arrangement of a sheet. 



DISEASES OF THE LARYNX. 433 

In the first, or catarrhal, stage counter-irritation is useful 
over the larynx by means of poultices of flaxseed-meal with 
mustard. The ice-bag (Fig. 78) may modify the intensity ot 
the inflammation. Gottstein advises not only these, but the use 
of leeches on the upper part of the sternum. 

Glasgow uses a spray of hydrogen dioxide thrown directly 
into the larynx. He believes the mechanical effect of the effer- 
vescence produced is to detach the false membrane and facili- 
tate its expulsion. For the purpose of increasing the secretion 
of mucus, which has a similar effect, menthol crystals may be 
employed by fusing a few in a teaspoon over a flame until the 
air is comfortably impregnated with the fumes. Inhalations of 
vinegar are highly recommended by some writers. 

Calomel, both internally and externally, has proved a valu- 
able remedy. It is believed to be potent in preventing the 
formation of an exudate. It increases the secretions, which 
action in itself contributes to the casting off of the false mem- 
brane. J. Dundas Grant reports favorable results from 1 -grain 
doses every four or six hours. With each dose he combines 3 
to 5 drops of wine of ipecacuanha and 3 to 5 grains of bromide 
of potassium. I have for a long time been satisfied that calomel 
was efficacious, and have employed it in smaller doses more 
frequently administered, | grain every two hours, until the 
bowels were considerably relaxed. I use the sodium bromide 
in preference to the potassium because it contains a larger per- 
centage of bromine and is not so vitiating to the blood. 

Fruitnight, in the Archives of Pediatrics for June, 1895, 
calls attention to the value of calomel fumigations in croup, 
whether looked upon as simple or specifically diphtheric. This 
treatment was originally suggested some years ago by Corbin, 
of Brooklyn, and later recommended by Dillon Brown. It 
should be used when there are symptoms of serious laryngeal 
involvement. " The amount of mercurial salt to be vaporized 
varies from 5 to 20 grains, repeated at intervals varying from 
one-half to two or three hours, according to the severity of the 
symptoms; in the average cases 15 grains hourly. The patient 
is to be kept in the vapor-saturated atmosphere, within a tent, 

28 



434 DISEASES OF THE EAR, NOSE, AND THROAT. 

for a period varying from ten minutes to one-half hour. In one 
hundred cases thus treated no case has been subject to dele- 
terious results. In one case only did slight ptyalism occur. 
Salivation, diarrhoea, depression, prostration, and anaemia must 
be prevented by watchfulness and proper treatment." (Year- 
book.) 

Emetics play an important role in the urgent stage of croup. 
When the larynx is filling to the degree of threatening suffo- 
cation a prompt emesis will often loosen the false membrane and 
effect its expulsion. To accomplish this I have most often used 
turpeth mineral (yellow sulphate of mercury) and with the most 
gratifying results. One or two doses will produce vomiting in 
a few minutes and afford marked relief. Ipecac, alum, and 
sulphate of copper are efficient. I have never tried the last of 
these three. One should guard against the tendency of parents 
or nurses, or wise and more meddlesome neighbors, to overdose 
children with emetics, on account of the exhaustion and the 
irritability of the stomach which they produce. When these 
measures fail, intubation or tracheotomy must be done. 

Children who are recovering from this disease have very 
sensitive throats and must be protected against cold air and 
draughts. They should be clothed throughout in woolen gar- 
ments, and kept in-doors until a normal condition of the larynx 
is re-established. Sprays of cubebs, camphor-menthol, lavolin, 
pine-needle oil, pine-tar, etc., will assist materially in a complete 
restoration of the mucous membrane to a state of health. 



CHAPTER XXXVIII. 
DISEASES OF THE LARYNX, CONTINUED. 

Intubation of the Larynx. 

To Joseph O'Dwyer, of New York, is due the credit of 
introducing the operation of intubation, which is now so com- 
monly performed. Bouchut, of Paris, demonstrated in 1858 
that the operation was practicable, but no practical results 
followed his discovery until O'Dwyer, without knowledge of 
Bouchut's work, showed actual recoveries due to it. 

The instruments for this procedure are a set of tubes' of 




Fig. 160.— O'Dwyer's Intubation-tubes. 



Fig. 161.— Scale. 



varying calibre, with a scale for measuring the tube, to assist in 
selecting the proper size; a mouth-gag (Fig. 149); an introducer; 
an extractor, and a protector for the surgeon's finger. 

The tube (Fig. 160) is constructed with a flaring top that 
rests upon the ventricular bands. On one side of the flange is 
an aperture through which a loop of thread sixteen inches long 
is passed before introduction, in order that, if the tube accident- 
ally pass into the oesophagus, instead of the larynx, it can be 
withdrawn. The obstruction of the tube with particles of 
membrane may also render it necessary to draw the tube out 

(435) 



436 



DISEASES OF THE EAR, NOSE, AND THROAT. 



ilk 



by the thread. It is safest to employ a strand of braided sill 
or linen thread, being certain that it contains no inequalities to 
catch in the fenestra. 

The scale (Fig. 161) is used to determine the size of the 
tube to be employed, according to the age of the patient. 




Fig. 162.— O'Dwybr's Introducer, with Tube Attached. 



The introducer (Fig. 162) is screwed into the obturator of 
the tube, as shown in the illustration, and, when the tube is 
inserted into the larynx, pressure on the button of the intro- 
ducer separates the obturator from the tube, leaving the latter 
in the larynx while the obturator is withdrawn. 

The extractor (Fig. 163) is so constructed that, when the 




Fig. 163.— O'Dwyer's Extractor. 



blades at the curved extremity are introduced into the mouth 
the tube, pressure on the lever will separate the forcep-blades. 
These are roughened so that they obtain a grip that insures the 
extraction of the tube when they are withdrawn. 

In addition to these instruments, one needs a protector 



DISEASES OF THE LARYNX. 437 

against being bitten during the operation. J. E. Rhodes (Jour- 
nal of the American Medical Association, January 15, 1895) 
has " devised a protector. It consists of a rubber glove that 
covers the hand from the wrist to a little beyond the metacarpo- 
phalangeal joints. On the index finger the terminal phalanx 
only is left uncovered." 

In order to prevent infection through the coughing of a 
patient while the operator occupies a position before his mouth, 
it is altogether safest to protect the eyes with glasses and the 
mouth and nose with a respirator or kerchief. 

The operation is a very brief one, not extending over ten 
seconds. The quicker it is accomplished, the less it interferes 
with respiration, and, therefore, with aeration of the blood. 
One should acquire not only extreme dexterity, but gentleness, 
in order not to do unnecessary damage to the delicate structures 
encroached upon. With proper skill one need inflict no injury 
or seriously interrupt breathing. In selecting the tubes it 
should be remembered that the smallest is intended for chil- 
dren younger than 2 years, the next for those between 2 and 4, 
the third smaller for those between 4 and 6, the fourth for 
those from 6 to 8, and the largest for those over 8 years of age. 

After the tube of proper size, according to the age of the 
child, as indicated on the scale, has been chosen, it is attached 
to the introducer by screwing the latter into the obturator con- 
tained within the tube, with the short side of the tube toward 
the handle, as shown. The latter is threaded as already de- 
scribed, and the instrument laid within easy reach of the right 
hand. Now, the child should be placed upon the lap of the 
nurse or assistant and held as shown in Fig. 150, illustrating 
the operation for removing adenoid vegetations from the vault 
of the pharynx. A strong sheet is wrapped and fastened about 
the child, so as to prevent any freedom of movements of its 
arms and legs, the latter being held between the nurse's knees. 
The nurse passes her left arm around the child's left side and 
over its arm, crosses the little one's wrists, and holds its right 
hand with her left and its left hand with her right, thus making 
it impossible for the child to interfere with the surgeon's work. 



i 



438 DISEASES OF THE EAR, NOSE, AND THROAT. 

One assistant places the mouth-gag, as shown in the figure 
referred to, with the gag resting between the molar teeth of the 
left side. He must attend assiduously to the holding of the gag 
in place and keeping the child's head, thrown a little backward 
on the nurse's shoulder, immovably fixed. If these directions 
are efficiently followed there can be no kicking, sliding down, 
snatching of the instrument, or dislocation of the gag. 

The introducer, with tube and obturator attached and 
previously warmed, is then taken, the thread loop is passed over 
the left little finger, and the left index finger, being oiled, is 
carried into the pharynx until its tip rests behind the epiglottis 
and holds it upward. Now the end of the tube is made to 
follow the course taken by the tip of the inserted finger until it 
rests directly beneath it. The tip of the finger readily recog- 
nizes the epiglottis and the opening between the arytenoid 
cartilages. The instant the end of the tube rests beneath the 
tip of the finger in the median line, the handle of the introducer 
is brought upward so as to pass the tube from this point straight 
downward into the larynx. Unless this direction is followed at 
this particular step of the operation the tube will pass back of 
the larynx into the oesophagus. The tube once in the larynx, 
the thumb pushes the slide and the tube is released, the intro- 
ducer withdrawn, and the finger still in the throat presses the 
tube down into proper position. 

The surgeon should not neglect the use of a finger-guard 
and some protector for his mouth and nose during the intro- 
duction of the tube. A bite of the child or the ejection of a 
diphtheric discharge may cost the operator his life or communi- 
cate the disease to others. 

Before introducing the tube it should be examined to see 
if the instrument work easily, if the tube is readily released, 
and if it will remain safely in position while it is being intro- 
duced. The larger the tube that can be used, the freer the 
respiration and the discharge of particles of membrane will be 
through it. 

The thread is best not removed from the tube directly after 
the insertion, for an increase in the embarrassment of the respi- 



- 



DISEASES OF THE LARYNX. 439 

ration may occur, indicating that either false membrane has been 
pushed along below the tube to block up its lower opening or 
that the lumen of the tube is obstructed by the presence of false 
membrane or secretions in it. In either condition the tube must 
be removed forthwith. So the thread loop is secured by attach- 
ing another thread to it and passing it around the child's neck. 
As soon as it becomes apparent that the operation has fulfilled 
its purpose by affording freedom of breathing, the gag is re- 
introduced, the thread is cut, the finger-tip placed on the end of 
the tube to prevent its dislodgment, and the thread loop is with- 
drawn, leaving the tube in position. If the operation has been 
successful, the patient, relieved of the horror of impending 
suffocation, now drops into a peaceful slumber, which must be 
encouraged, in order that nature may recuperate its waning 
strength and fortify its resisting-powers. 

Pellets of ice may now be allowed the patient to suck for 
quenching the thirst and to teach swallowing with .the tube in 
place. Later a few drops of cold milk are given for the same 
purposes. 

Should the first attempt to introduce the tube fail, the 
child must not be exhausted by too immediate an attempt for 
the second trial. A little rest is always best, unless the dyspnoea 
is exceedingly urgent. If the intubation fail or is followed by 
no relief, tracheotomy is the last resort. The physician should 
always be prepared for this emergency by having the trache- 
otomy instruments at hand. 

A bottle of nitrite of amyl should be provided, for, in case 
of threatened collapse, the inhalation of a few drops of it may 
resuscitate the little patient. 

To remove the tube the patient is prepared the same as for 
its introduction. The extractor is carried down, under the 
guidance of the tip of the protected left index finger, until it is 
slipped into the opening of the tube, when the lever is pressed 
upon by the thumb, the forcep-blades expanded to engage the 
tube, and the instrument is withdrawn with the tube attached. 
One must not forget to keep up the pressure that holds the 
tube attached to the extractor, or the tube might drop back into 



440 DISEASES OF THE EAR, NOSE, AND THROAT. 

the throat. Removal of the tube may be necessary to clear it 
of obstructions or to ascertain when the patient no longer re- 
quires it. Should it be necessary to re-introduce it, a second 
tube had best be at hand already attached to the introducer, so 
that, if great dyspnoea occur before one has had time to clean 
and thread the tube removed, the other one can be inserted 
without delay. In case no other tube is at hand Northrup 
advises to " thrust the obturator into the tube and take two 
turns of thread of any kind around the neck of the tube, 
gathering the two ends in the right hand as it grasps the handle. 
In this way the thread holds the tube to the obturator during 
the insertion, and when it is in the larynx unwinds from the 
shaft and is drawn away." 

After the tube lias been in the trachea for a quarter of an 
hour, and there are no indications that it will have to be re- 
moved, the loop of thread is cut, and, with the finger in the 
pharynx and resting on the end of the tube the same as on its 
introduction, the string is withdrawn. Care must be taken not 
to disturb the tube in doing so. While the thread is in the 
mouth it excites nausea and gagging. 

The tube is allowed to remain in the larynx for several 
days, sometimes five or six, but, as soon as it becomes ap- 
parent that the disease has progressed so favorably as to render 
its presence there unnecessary, it is extracted. Sometimes it is 
coughed out. 

In the course of three or four hours after intubation the 
larynx becomes accustomed to the presence of the tube ; but if 
fluids are administered in a sitting posture they are almost cer- 
tain to enter the larynx and excite violent coughing, which may 
expel the tube, or they may enter the lungs and cause pneu- 
monia. The safest way to feed these patients is that proposed 
by Frank Cary, of Chicago, as follows : The patient is placed 
upon his back, with his feet elevated so that the axis of the body 
rests at an angle of forty-five degrees with the plane of the floor. 
The fluids are given through a tube or nursing-bottle in this 
position ; then they do not gain entrance into the trachea. 
Solids do not enter the trachea. Custards, corn-starch, thick 



DISEASES OF THE LARYNX. 441 

gruels, etc., are quite readily taken, and many children soon 
learn to eat and drink with the tube in position. 

Intubation is to be preferred to tracheotomy in children 
under 5 years, particularly with an abundance of adipose tissue 
overlying the trachea. Parents more readily consent to this 
procedure than to an operation that involves the use of the 
knife. Intubation produces less shock than tracheotomy, and 
the air is better prepared for contact with the mucous mem- 
brane below the trachea after intubation than when it enters 
directly through a tracheotomy-tube. No anaesthesia is required 
for intubation, but it is generally necessary in tracheotomy, 
although I have operated without an anaesthetic in case of 
emergency. I have seen cases requiring tracheotomy in which 
the time necessary to produce anaesthesia could not be sacrificed, 
and, indeed, the carbonic-acid poisoning produced a sufficient 
anaesthesia. 

There are instances in which intubation fails because the 
tube cannot be retained in position, or sufficient nourishment 
cannot be taken to support the waning strength, or the tube 
becomes so clogged that it has to be removed repeatedly. In 
these cases tracheotomy will have to be brought to our aid. 
Intubation is not difficult for the laryngologist, but one needs 
considerable practice in order to be reasonably sure of success. 
The best means of acquiring dexterity is to introduce a tube 
frequently into the larynx of a cadaver. In the absence of 
conveniences for this, the tube should be many times introduced 
and extracted by means of substituting a hand, preferably that 
of another, for the larynx. The tube should be placed com- 
pletely out of sight in the hand while its mouth is sought for 
with the extractor. But it should not be forgotten that the 
passive hand differs somewhat from an obstreperous, struggling 
child. Intubation requires two assistants, and, if possible, one 
of these should be able to remove the tube or to introduce it if 
it is necessary to remove it or if it is coughed up. So in case 
of intubation it is important that skilled assistance be at hand 
for these emergencies. 

Tracheotomy is easier to perform, and can be done in ex- 



442 



DISEASES OF THE EAR, NOSE, AND THROAT. 



tremities without skilled assistants. If the tube become clogged 
the nurse can prevent suffocation by removing it and maintain- 
ing the opening free until the surgeon arrives. In these respects 
tracheotomy presents advantages over intubation. In cities 




Fig. 164.— Roswell Park's Aluminium Tracheal Tube. 

where skilled laryngologists are within quickly-calling distances 
intubation possesses superior merits. In the country, with all 
its unavoidable disadvantages, tracheotomy is hardly likely to 
be superseded. 

Tracheotomy. 

The instruments necessary for this operation are a small 
knife, double retractors (Fig. 88), haemostatic forceps, tracheal 




Fig. 165.— Hard-Rubber Tracheal Tubes. 



forceps, a tenaculum, a grooved director, a flexible catheter, 
and tracheotomy-tubes of various sizes (Figs. 164 and 165). 
The average size, up to 3 years, is one-fourth inch (six milli- 
metres). Other convenient articles should be at hand, if 



DISEASES OF THE LARYNX. 443 

circumstances permit of their being supplied : sharp-pointed 
forceps, an aneurism-needle, thread, absorbent gauze, and tapes. 

An anaesthetic should be given unless the requisite time 
would endanger life, or the diminution of the amount of oxygen 
reaching the lungs would add to a danger already imminent, or 
unless the sensibilities are sufficiently obtunded by carbonic-acid 
poisoning of the blood. In this operation chloroform is to be 
given the preference over ether, on account of the effect of 
ether in exciting glottic spasm and increasing the difficulty of 
respiration. 

The high operation, in which the trachea is entered above 
the isthmus of the thyroid gland, is generally to be preferred to 
the low one, in which the incision is made below the isthmus, 
since in the high operation there are fewer and smaller blood- 
vessels to encounter (Plate VII). Another advantage gained 
in the high operation lies in the more superficial position of the 
trachea. 

The position of the patient during the operation is upon 
the back, with the head thrown backward by means of a narrow 
support under the back of the neck, to force upward promi- 
nently the anterior surface of the neck. If the operation is 
done without anaesthesia, the head, hands, and legs must be 
held by assistants. 

The incision is made in the median line, over the cricoid 
cartilage, for the high operation, extending an inch or more 
above and below the cartilage. The superficial anterior jugular 
vein may be met with at this point, and requires to be drawn 
out of the way or doubly ligated and divided ; but, if there is 
need for great haste, it can be secured by haemostatic forceps 
until after the trachea is opened. The superficial fascia is 
opened, the grooved director inserted, and the incision is com- 
pleted, after which the deep fascia is similarly incised. The 
knife-handle is used to separate the sternohyoid and the sterno- 
thyroid muscles ; the double retractors (Fig. 88) are now 
inserted to keep the wound open and to check haemorrhage by 
their pressure on its sides. The rings of the trachea can easily 
be felt, and the isthmus of the thyroid gland may protrude 



444 DISEASES OF THE EAR, NOSE, AND THROAT. 






sufficiently to necessitate its being drawn down out of the way. 
A transverse incision is now made, about one-half inch (one 
centimetre) long, over the superior border of the cricoid carti- 
lage, penetrating the superficial layer of the deep cervical fascia. 
The grooved director is then introduced, passing from above 
downward between the cricoid cartilage and the deep layer of 
the deep cervical fascia. The two layers of fascia with the 
intervening veins and thyroid isthmus are drawn downward, 
exposing the upper rings of the trachea. These are fixed by 
the tenaculum and divided by an incision about one-half inch in 
length, according to the age of the patient. Great care must 
be taken that the knife does not penetrate the posterior wall 
of the trachea and the oesophagus. Equal forethought should 
insure that the false membrane is penetrated, so that the tra- 
cheal tube shall not be inserted between the membrane and the 
wall of the trachea, thus blocking up its opening. Equal care 
must be used to avoid the entrance of blood into the trachea 
and lungs. Coughing generally occurs when the trachea is 
opened, so that the secretions and portions of the false mem- 
brane are expelled. In case of diphtheria it is evident how 
necessary it is for the physician to be on the alert to dodge the 
bombardment of poisonous discharges. 

The trachea being opened, a dilator is employed by many 
surgeons until the haemorrhage ceases and free respiration is 
established. Sponging must be rapid ; the opening must be 
maintained free from discharges ; all false membrane within 
reach of the tracheal forceps must be extracted, and, finally, the 
tracheal tube is introduced and secured by tapes passing around 
the neck and tied on one side. As large a tube as the trachea 
will admit should be used. The patient must be closely watched 
and, if necessary, artificial respiration must be performed ; clog- 
ging of the tube and interference with it must be prevented. 
All the tissues about the wound should be cleansed with a 
solution of bichloride of mercury, 1 to 5000, and a divided 
piece of gauze, smeared with carbolized vaselin, should be 
interposed between the collar of the tube and the surface of the 
wound. 






DISEASES OF THE LARYNX. 445 

The low operation is performed similarly to the one already 
described, except that the incision begins at the cricoid carti- 
lage and ends about one-half inch above the sternum. The 
trachea lies deeper here ; the blood-vessels are larger and more 
numerous and the thyroid isthmus is in the way. It is a more 
difficult procedure. 

After tracheotomy the tube is best protected by a layer of 
bichloride gauze kept loosely above and about the tube, without 
impeding the currents of air. As rapidly as it is soiled this 
protector should be removed. The air of the apartment is kept 
at a uniform temperature of 76° to 80° F., and impregnated 
with moisture to prevent irritation of the mucous membrane of 
the deeper air-passages. During the first day the inner tube 
must be removed frequently for cleaning with a 5-per-cent. solu- 
tion of carbolic acid, and to make certain that there is no 
obstruction. Sections of the false membrane may block up the 
lower end of the large, or outer, tube and require removing with 
the tracheal forceps. In such an emergency the cannula has to 
be removed. The nurse should always be instructed as to the 
possibility of such an accident, and that she must at once cut 
the tapes, remove the tube, cleanse and free the opening, and 
maintain its patency until the surgeon can be summoned. In 
two or three days the tube should be closed momentarily to 
determine if respiration is normal without it ; if so, it can be 
dispensed with and the wound closed. 



CHAPTER XXXIX. 

DISEASES OF THE LARYNX, CONTINUED. 

Chronic Laryngitis. 



Synonym. — Chronic catarrh of the larynx. 

Explanatory Note. — Before entering upon a consideration 
of this subject it is pertinent to explain why there is no separate 
article in this book, as is customary, on subacute inflammation 
of the larynx. There are many varying degrees of inflammation 
of the mucous membrane. During the same attack of acute 
inflammation the process exhibits different degrees of intensity, 
but the tendency of our times has been too much toward useless 
and confusing refinements and multiplication of pathological 
conditions into entities, when they were really but modifications 
of the same disease, like shades of the same color or variations 
of the same malady. Formerly the mild grade of acute inflam- 
mation of the middle ear was described separately as a subacute 
inflammation, although it is not a different disease ; but the lead- 
ing books on otology now discard this adventitious distinction, 
and laryngologists should lend encouragement to a sensible 
simplification of a terminology which is encumbered with un- 
warranted parasites of nomenclature. So we will not attempt 
to multiply the varying grades of intensity of an acute inflam- 
mation into separate diseases. 

Pathology. — When acute laryngitis is neglected it naturally 
terminates in a chronic inflammation, which leaves the mucous 
membrane thickened and the small blood-vessels engorged and 
tortuous. There is an increase in connective-tissue formation, 
the encroachment of which on the epithelial layer produces the 
superficial erosions occurring in this disease. The posterior por- 
tion of the cavity only may be involved, or the inflammatory 
process may extend to every part of the larynx, not excepting 
the muscles. When the latter become indurated the mechanism 
of pitch-production is so interfered with as to render its changes 
(446) 






DISEASES OF THE LARYNX. 447 

very difficult. If the mucous membrane covering the vocal 
cords is thickened, the result is an alteration in the timbre or 
quality of the voice, which assumes a hoarse sound. 

Etiology. — As chronic rhinitis is the direct result of re- 
peated or neglected attacks of acute nasal catarrh, so chronic 
laryngitis may be a sequel of recurring or neglected attacks of 
acute catarrh of the larynx. But this disease is not always a 
heritage of an acute attack. It often arises cle novo. Many pa- 
tients who are afflicted with chronic hypertrophic rhinitis present 
a chronic laryngitis as a complication or result of the nasal hy- 
pertrophy. This is easily understood when we take into con- 
sideration the continuity of mucous membrane of the larynx, 
pharynx, and nasal cavities. In addition to this direct cause is 
another which illustrates the importance of prompt and efficient 
treatment of nasal anomalies. The discharges from the nose 
and naso-pharynx constantly find their way either directly into 
the larynx by dripping into the cavity, or they gravitate down 
to the immediate vicinity of the portal of the larynx, where 
they cause direct irritation by their presence, and indirect irrita- 
tion by exciting efforts to dislodge them, with a hacking cough. 
Bosworth lays stress upon this source of chronic laryngitis. 

Another causative relation of hypertrophic rhinitis to this 
disease lies in the forced mouth-breathing in consequence of 
nasal stenosis. The air then reaches the larynx without the 
processes of purifying, warming, and moistening having been 
applied to it as they are by the nasal passages in a normal 
condition. 

Excessive use of the voice, especially when it is taxed 
beyond its natural or acquired compass, sets up an hyperemia 
and congestion that finally terminate in a chronic inflammation. 
Ambitious, but ill-trained singers, the periodical orators of polit- 
ical campaigns, hucksters, intensely-emotional revivalists, etc., are 
frequent sufferers. Inactivity of the liver, and dyspepsia, alco- 
holic excesses, and atmospheric irritants are prolific producers 
of this disease. 

Symptomatology. — The most marked symptoms are devel- 
oped when attempts are made to use the voice. While it is at 



448 DISEASES OF THE EAR, NOSE, AND THROAT. 

rest there may be very little to call the patient's attention to the 
fact that he has a larynx. In other instances there is a sensa- 
tion of dryness or a slight irritation that excites a hemming or 
a little cough. But when the patient begins to call the vocal 
organs into activity the trouble begins. A tickling sensation 
is experienced that produces an irresistible desire to cough. 
Burning and prickling pains are felt in the larynx, which one 
endeavors to relieve by clearing the throat. In the midst of a 
sentence a cutting pain shoots through the organ, that may be 
described as a feeling as though the vocal cord were splitting or 
tearing. The sentence, or even the word, is cut short, and for 
an instant the speaker is unable to proceed until he clears the 
throat or takes a drink ; hence arises the habit of many speak- 
ers of providing themselves with a glass or a pitcher of water 
before beginning a discourse. 

The voice shows the most marked effect of this disease, 
but there are great variations in different patients, and pecul- 
iarities distinguishing certain cases. When a speaker, for ex- 
ample, begins an address, his voice may be husky and cracked 
in quality, while, after proceeding for a short time, the normal 
timbre may be restored. Singers experience the same pecul- 
iarity. This is probably due to the increased secretion stimu- 
lated by a quickened circulation, as well as to improved inner- 
vation resulting from the intensity of will-impulse. Another 
characteristic is the natural quality observed in the customary 
tones and the breaking of this quality on straining the voice, 
and even a condition of complete aphonia, or loss of voice. 

The secretions are not copious from uncomplicated chronic 
laryngitis. They are generally tenacious and of a gray color, 
but if ulcerations are present they assume a yellow hue. As in 
the acute inflammation, there is rarely any blood in the expecto- 
rations, unless an unusually violent effort at coughing has 
ruptured the vessels. 

Inspection with the laryngeal mirror shows an hypersemic 
condition of the mucous membrane (Plate VIII). As the 
figures illustrate, the small blood-vessels of the epiglottis are 
engorged and conspicuous. The vocal cords are sometimes red, 






DISEASES OF THE LARYNX. 449 

one or both ; at other times they do not participate in the in- 
flammatory process. One cord may be affected, while the other 
remains of normal appearance, or parts only of the cords may 
show an injected condition of their blood-vessels. These parts 
are the lateral attached borders of the vocal bands. The con- 
dition of the membrane varies, according to the amount of 
secretions present, from absolute dryness to a general covering 
of the whole interior with secretions. Like similar conditions 
of the mucous membrane in other localities, a gradual thicken- 
ing of the mucosa and submucous tissues results from inflam- 
mation of long duration, and the vocal cords may be affected 
by this hyperplasia to the extent of granulation formation, or 
trachoma. The presence of these excrescences materially em- 
barrasses the vibration of the cords and changes the character 
of the notes produced. 

The chronic thickening of the mucosa and the subjacent 
tissues diminishes the mobility of the larynx, just as we have 
seen that the increased thickness of the drum-head and of the 
tissues entering into the construction of the joints of the ossicles 
and the attachment of the stirrup to the oval window diminishes 
or destroys their mobility. For example of impeded movements 
due to hypertrophy : when the interarytenoid fold becomes 
thickened the arytenoid cartilages cannot approximate each 
other normally, which is equivalent to saying that the vocal 
bands cannot do the same thing. Great swelling of the ven- 
tricular bands obliterates the ventricles and deranges the actions 
of the vocal cords. One cord becomes paretic and the opposite 
cord must do vicarious service, which it does by taking the 
place, almost literally, of its fellow, by moving across the median 
line to approximate its useless mate. The gap is then closed 
up, to a degree, and voice-production is made possible. 

Ulcerations of a shallow kind are occasionally to be seen, 
generally in the interval between the arytenoid cartilages. 

Diagnosis. — Chronic laryngitis is likely to be confounded 
with laryngeal oedema, paralysis, and cancer, or syphilitic and 
tubercular laryngitis. In oedema the swelling of the mucosa is 
out. of all proportion to the thickening of chronic inflammation, 

29 



450 DISEASES OF THE EAR, NOSE, AND THROAT. 

and, although there may be redness, there is generally a pale, 
puffy, and water-soaked appearance, and the disease is of short 
duration. In paralysis neither swelling nor congestion is 
present. In the catarrhal condition hoarseness is generally 
more apparent in the morning hours, while the change in char- 
acter of the voice in paralysis is constant, but less noticeable 
immediately after a night's rest. Paresis in the catarrhal con- 
dition more often affects one vocal band than both, according 
to Ziemssen ; and the absence of mobility is much greater in 
paralysis. In catarrh the use of the voice often has the effect 
of clearing it of its cracked quality, while in paralysis fatigue 
and vocal exercise impair its quality. 

Tubercular laryngitis presents a very different history from 
that of the simple catarrhal disease. The general condition of 
the patient and the presence of a tubercular condition of the 
lungs assist materially in making a differential diagnosis. The 
impaired nutrition and strength, the temperature and pulse, the 
night-sweats, and painful and difficult swallowing are character- 
istic of tuberculosis, but not of chronic laryngitis. The intra- 
laryngeal pictures show certain differences in the two diseases. 
While redness is a symptom of catarrhal inflammation, the 
membrane in tuberculosis of the larynx may present a bloodless 
appearance, especially in the initiatory stage of the disease. 
Erosions, rare in simple catarrh, are characteristic of the tuber- 
cular affection. In laryngitis of the simple type, even when 
the erosions are found, they are superficial points of exfoliation 
of the epithelium ; but in tuberculosis they may extend deeply 
into the membrane and be distributed over a wide area (Plate 
VIII), affecting the epiglottis, the posterior commissure, the 
ventricular bands and the vocal cords. The polypoid con- 
formation of the arytenoid cartilages produced by the great 
thickening in advanced cases is well illustrated in the plate to 
which reference is made. This swelling extends to the aryepi- 
glottic folds and appears dense instead of cedematous, although 
the paleness of the membrane may be suggestive of a case of 
oedema. 

Syphilis of the larynx (Plate VIII) may closely simulate 



DISEASES OF THE LARYNX. 451 

a simple catarrh, but a syphilitic history or the presence of 
ulcers or their scars, and deformities due to the contraction of 
old cicatrices are valuable aids to diagnosis. The effects of the 
administration of specific remedies in experimental diagnosis 
are determinative in syphilis. 

In both tuberculosis and syphilis of the larynx character- 
istic lesions in the pharynx may help greatly in arriving at a 
correct conclusion. 

Chronic laryngitis may be with difficulty distinguished from 
a malignant disease, at first, but the histories of the two con- 
ditions vary. In the early stage of malignant disease the red, 
tumefied appearance is limited to a certain area instead of being- 
diffused over a large surface. As the neoplasm increases in 
size it changes the contour of the parts as simple catarrh does 
not, and difficult and painful swallowing, together with loss of 
voice, are marked symptoms of malignant disease. As deep 
ulceration in the latter condition takes place the pain is more 
pronounced and continuous than is met with in simple chronic 
laryngitis. 

Prognosis. — If the disease has not existed too long, and 
proper treatment and hygienic conditions can be had, the out- 
look is favorable. But if thickening of the tissues is great and 
extends to the laryngeal muscles, the difficulties to overcome 
are considerable. This trouble is usually protracted and extends 
over many years, in some cases, and, after treatment has accom- 
plished all it will, the voice may still retain a coarse, unpleasant 
quality. 

Treatment. — The topical application of remedies is easily 
accomplished with the improved apparatus of our day. Com- 
pressed air and sprays can be made to apply medicaments to the 
interior of the larynx with ease and efficiency. Useful devices 
are shown in Chapter XVIII for both office and home treat- 
ment. Improved appliances for compressing air, both by hand 
and hydraulic power, are described in Chapter IV. 

Various medicated sprays — as recommended by Lennox 
Browne, E. L. Shurly, Charles E. Sajous, and others — will 
cleanse and disinfect the larynx, as well as produce astringent, 



452 



DISEASES OF THE EAR, NOSE, AND THROAT. 



sedative, stimulant, or tonic effects. It is claimed by Roe and 
Cohen that sprays thrown into the throat are largely condensed 
in the pharynx, but it can be easily demonstrated upon one's 
own larynx that the remedy can be made to medicate that organ 
also. If the spray is thrown through a long tube with a prop- 
erly-curved extremity (Figs. 116 and 117) for directing the 
current downward and a little forward from a position similar 
to that occupied by the laryngeal mirror in situ, the spray enters 
directly into the larynx. When the dilator is used with the 
lips closed over the mouth-tube and the patient inhaling through 
the instrument, the medicinal vapor not only reaches the laryn- 
geal cavity, but the bronchi and lungs also. In former years 
I used the complete steam-atomizer of Codman & ShurtlefT, 
but, as I could discover no compensating advantage of the 
steam method over the improved apparatus referred to, and as 




Fig. 166.— Cohen's Sponge- or Cotton- holding Forceps. 



?at- 



the latter requires far less time and trouble in giving trea 
ments, I have for a considerable time preferred the instruments 
described. 

For the application of pigments to the laryngeal membrane 
special camel's hair brushes, sponges, and cotton are used. I 
prefer the cotton, either twisted firmly on a holder or used with 
Cohen's laryngeal cotton-forceps (Fig. 166). The bristles of 
the brush sometimes become detached and stick in the larynx, 
like the voice of iEneas. This is not amusing to the patient. 
Applicators for caustics are specially constructed, but, with a 
minute cotton-tip twisted very firmly on a carrier, escharotics 
can be conveniently applied. 

Counter-irritants, like mustard and tincture of iodine, are 
sometimes serviceable. They should be applied directly over 
the larynx and at its sides. It is exceedingly important that 



DISEASES OF THE LARYNX. 453 

the cause of the trouble be removed, and this will generally be 
found to lie in inordinate and improper exertion of the voice. 
In such cases absolute rest must be enjoined. When the cough 
is very troublesome the compound spirit of chloroform or Hoff- 
mann's anodyne will relieve the irritation. The inhalation of 
camphor-menthol from the pocket-inhaler (Fig. 128) allays the 
tickling. 

When the thickening is considerable, sprays of eucalyptol, 
4 per cent.; camphor-menthol, 3 per cent.; or oil of cubebs, 4 
per cent., in lavolin should be used once or twice a day. Alum, 
in a 2-per-cent. solution ; zinc sulphate, 1 per cent. ; or silver 
nitrate may be used according to the indications in each case. 
When much irritability exists, with a hacking cough and co- 
pious secretions and expectoration, inhalations of a 10-per-cent. 
solution of camphor-menthol in lavolin are effective. These 
should be taken through the nebulizer, and not in the form of 
a coarse spray. 

If erosions are discovered the dioxide of hydrogen, diluted 
one-half with water, at first, should be sprayed upon the ulcers; 
then aristol should be sprinkled over them. Iodoform is pre- 
ferred by some, tannin and alum by others. Chromic acid, 5 
or 10 grains to the ounce, and silver nitrate have able advocates. 

Atrophic Laryngitis. 

This requires stimulating applications. The lavolin-sprays 
containing remedies already given are useful, — viz., eucalyptol, 
oil of cubebs, benzoinated lavolin, menthol, terebene, salol, oil 
of tar, etc. Shurly recommends iodine internally in the form of 
hydriodic acid, in drachm doses, three times a day, or iodide of 
potassium or ammonium. Much relief is afforded by my am- 
monium-chloride tablets, the formula of which will be found 
under " Treatment" of "Acute Laryngitis." Two or three can 
be used in the course of an hour, allowing them to dissolve 
slowly in the mouth, so that the medicated saliva will trickle 
down and remain in contact with the mucous membrane about 
the entrance to the larynx as long as possible. 



454 diseases of the ear, nose, and throat. 

Suppurative Laryngitis. 

Synonyms. — Phlegmonous laryngitis; purulent laryngitis; 
diffuse abscess of the larynx. 

Pathology. — This is an inflammation of the submucous tis 
sues of the larynx, with infiltration of the areolar tissue and 
suppuration, ending in the formation of abscesses. The area 
most frequently involved is the superior part of the larynx 
contiguous to the epiglottis. 

Etiology. — Suppurative inflammation of the larynx may be 
idiopathic, or it may arise secondarily by extension from the 
pharynx. It may originate in perichondritis secondary to 
syphilitic infection or other wasting disease. 

Symptomatology. — Difficult respiration and impairment or 
suppression of the voice are the most prominent symptoms. 
There is a choking or stifling sensation, as though a foreign 
substance had gained entrance into the larynx, accompanied by 
increasing pains. Some difficulty in deglutition appears ; all 
the symptoms become exaggerated; the breathing is strident, 
the voice feeble and cracked, the face puffed and purple, and 
suffocation seems imminent. Frequent attempts are made to 
free the throat by hemming rather than by coughing. Laryn- 
goscopy reveals the inflamed, tumefied mucous membrane ob- 
structing the air-current. Circumscribed swelling may be seen 
in the region of the aryteno-epiglottic folds. 

Diagnosis. — Inspection discloses the differences between 
this disease and the presence of foreign bodies, diphtheria, 
croup, tumors, pharyngeal abscess, and spasmodic croup. The 
dyspnoea of this disease appears more gradually than that occa- 
sioned by the presence of foreign bodies or laryngismus strid- 
ulus, in which the obstruction to breathing occurs suddenly. 
The history of a tumor does not present the characteristics of 
an inflammation. 

Prognosis. — Suppurative laryngitis is a rapidly-fatal disease. 
It kills about three out of four of its victims. Death is caused 
by strangulation or inanition. 

Treatment. — If the patient is seen at the onset of the at- 



; 



DISEASES OF THE LARYNX. 455 

tack, cold, in the form of ice-bags (Fig. 78), should be constantly 
applied over the larynx. Pellets of ice may be sucked so as to 
produce the effect of cold internally as well as externally. 
Leeches may be applied over the upper portion of the sternum, 
but in this disease there is one objection to them that may not 
have weight in other diseases of the larynx, — i.e., the patient 
soon becomes exhausted from the lack of nourishment, owing 
to the impossibility of swallowing sufficient food, and bleeding 
only adds to his weakness. The air should be kept moist the 
same as in croup. (Edematous tissue and abscesses must be 
evacuated by scarification. Supportive and stimulant treatment 
must be combined with nutritious enemata to meet the inevi- 
table failure of strength. Suffocation must be prevented by 
tracheotomy or intubation. 

Abscess of the Larynx. 

The physical conditions in this disease coincide so closely 
with those just described under the heading of " Suppurative 
Laryngitis," in which abscesses occur, that a separate description 
would be tantamount to tautology. The treatment is the same 
as for abscesses occurring in suppurative laryngitis. 

Granulations of the Vocal Cords. 

As a result of chronic laryngitis of long duration, a rough- 
ened condition of the vocal bands is found, to which the name 
" chorditis tuberosa " is sometimes applied. There is a prolif- 
eration of connective tissue, productive of inequalities that are 
apparent in the laryngoscopic image. This condition obtains 
most frequently in public speakers and singers and is sometimes 
quite intractable to treatment. 

Treatment. — The remedies recommended for chronic laryn- 
gitis are applicable here. Charles E. Sajous advises applying 
chromic acid to the cocainized hypertrophies. This is best 
accomplished by fusing the acid on the applicator (Fig. 66), 
bent to the proper curve. Only a few of the prominent points 
should be touched at each treatment. 



456 DISEASES OF THE EAR, NOSE, AND THROAT. 



QEdexMA of the Larynx. 



.. 



Synonyms. — (Edematous laryngitis ; purulent laryngitis ; 
oedema glottidis. 

Pathology. — The loose attachment of the mucous mem- 
brane to the walls of the larynx favors infiltration and separation 
of the mucosa from the cartilages (Plate VIII). The changes 
that take place in acute cedematous inflammation occur so rap- 
idly as to preclude their study, the disease proving rapidly fatal 
in many cases. In this form the infiltration consists of serum, 
but in the more protracted attacks it consists of a mixture of 
serum and pus, with effusion of blood, in occasional instances. 
The epiglottis is sometimes involved to the extent of becoming 
greatly enlarged. The loose areolar tissue of the aryepiglottic 
folds is probably more copiously engorged with the fluid exu- 
date than any other portion of the larynx, and the ventricular 
bands suffer nearly as much. The true vocal bands may escape 
altogether or participate to the degree of slight swelling. The 
laryngeal muscles may present a water-soaked appearance if a 
post-mortem examination is made, after death due to this disease. 
Associated with oedema of the larynx may be a similar infiltra- 
tion of the pharynx and even of the neck. 

Etiology. — Most cases of laryngeal oedema occur between 
the ages of 20 and 35 years, and are nearly three times as 
frequent in men as in women. It may be idiopathic or symp- 
tomatic. Nearly three times as many cases are secondary as 
are primary in character, — that is, most cases are consecutive to 
some other affection, such as Bright's disease, that gives rise to a 
dropsical condition of lax tissues. When oedema of the pharynx 
invades the adjacent laryngeal tissues, the latter is termed " con- 
tiguous oedema " ; and when laryngeal oedema is secondary to 
some other disease of the larynx it is designated as consecutive. 

Any cause that operates to produce an inflammation of the 
laryngeal mucosa or submucosa may be a cause of oedema. 
Exposures to cold or impure air containing irritating particles 
or gases, injuries, scalds, corroding chemicals, and certain dis- 
eases cause or predispose to this disease. Such affections as 



DISEASES OF THE LARYNX. 457 

Bright's disease, syphilis, tuberculosis, and typhoid and the 
eruptive fevers. 

Symptomatology. — The prominent and most distressing 
symptom is the difficulty of respiration. There is a sensation 
as if a foreign body had gained entrance into the throat, and 
difficulty of swallowing adds to the suffering. As the swelling 
and consequent stenosis of the larynx progresses, the labor of 
breathing becomes more arduous, until the patient is threatened 
with impending suffocation. As the lumen of the larynx is 
encroached upon, and the pressure of the tumefied tissues 
increases, the voice becomes feeble and finally disappears. 

Frequent efforts are made to clear the throat of the ob- 
struction, but they are not of the character of a cough. There 
is but little expectoration, and this consists of mucus. The suf- 
fering occasioned by this disease is intense, not only of the pa- 
tient, but of his helpless friends. He cannot lie down, but sits 
with his body and head thrown forward, unable to speak, but 
exerting every muscle to draw in enough air to support life. 
He calls to the by-standers for help, has them support his 
arms and shoulders, one attendant on either side, while he seeks 
the open window for air. The noise of inspiration is harsh and 
indicative of the extreme narrowing of the glottis. Moments 
of relaxation and relief may occur, only to be followed by the 
paroxysm that threatens immediate suffocation. As the sufferer 
gasps for air with open mouth and horror-stricken eyes, his face 
puffed and purple, his whole frame convulsed with an agoniz- 
ing struggle for life, the surgeon or death soon comes to his 
relief and closes the scene. 

Inspection, when it is possible, reveals the epiglottis red 
and swollen to enormous proportions, and it may cut off a view 
of the laryngeal cavity. The enlargement becomes so excessive 
as to amount to a deformity. The aryepiglottic folds are seen 
to be tumefied even to the point of medial contact with each 
other over the laryngeal opening during inspiration. 

When inspection is impossible, a quick, but gentle, palpa- 
tion with the finger, not interrupting respiration to a dangerous 
degree, may enlighten the examiner as to the condition present. 



458 DISEASES OF THE EAR, NOSE, AND THROAT. 

The roll-like character of the epiglottis and the spongy feeling 
of the aryepiglottic folds are characteristic. 

Diagnosis. — (Edema of the larynx may be mistaken for the 
presence of foreign bodies, polypus, retropharyngeal abscess, 
acute laryngitis, or pulmonary emphysema. The symptoms and 
the conditions presented on examination are sufficient to mark 
the differences. Diphtheria of the larynx can be detected by 
the discharge of shreds of the false membrane and the latter 
is generally found in the pharynx also. 

Prognosis. — About one-half of all cases of this disease 
terminate fatally. Acute laryngeal oedema has an average dura- 
tion of about a week. Cases arising in the course of pharyn- 
geal oedema generally pursue a favorable course, but those re- 
sulting from aneurism of the aorta or of other important vessels 
of the neck prove fatal. The same is true of oedema arising 
from an extension of the disease from the external areolar tissue. 
Tubercular oedema is unfavorable, but the syphilitic type is amen- 
able to treatment. The prognosis should always be guarded. 

Treatment — Scarification is the classic remedy, but there 
are other means of relief that have come into use in later years. 
Pilocarpine depletes the blood-vessels of their serum and is in- 
dicated here to drain the water-soaked tissues. It can be given 
in doses of \ or J grain until free salivation and diaphoresis are 
produced. Enough to cause heart-depression should not be 
administered. 

In violent acute cases the blanching, shrinking, and anaes- 
thetic effects of cocaine would appear to be indicated. I have 
never tried it in this condition, nor have I seen it mentioned 
in this connection, but for prompt action and immediate relief 
from impending suffocation its physiological action suggests 
its use. Unless a speedy change for the better takes place, 
scarification, intubation, or tracheotomy should be done. 

When oedema has become chronic, its treatment is much 
like that of chronic laryngitis, with the addition of scarification. 
Dilatation by Schrotter's method with hard-rubber tubes has 
proved useful, and the intubation-tubes, promise good results. 
In severe cases tracheotomy may become imperative. 









CHAPTER XL. - 

DISEASES OF THE LARYNX, CONTINUE©. 

Neuroses, 
spasmodic croup. 

Synonyms. — Spasm of the larynx ; spasm of the glottis ; 
laryngismus stridulus. 

Pathology. — According to Marshall Hall, this is a reflex 
nervous disease, the exciting cause of which may be located in 
remote organs, — for example, in the teeth, the intestinal tract, 
or at a point of pressure on the recurrent laryngeal nerve. It 
is believed by some authorities to be of purely cerebral origin. 

Etiology. — This is, for the most part, a disease of childhood, 
although it occasionally occurs in adult life. It may be brought 
on by the accidental entrance of liquid or foods or any foreign 
body into the larynx. Dentition is a common cause, and mental 
emotion may give rise to attacks. 

Symptomatology. — The closure of the glottis may be com- 
plete or incomplete. In the former case there is entire arrest 
of respiration temporarily. The child is taken with a sudden 
convulsion; the eyes are rolled ; the hands and feet are cramped, 
and even opisthotonos may supervene. All at once a spasmodic 
inspiratory movement occurs, announcing the cessation of the 
spasm. When the glottis is incompletely closed, the air passes 
through it with a harsh, croupy sound, which resembles closely 
the crowing of croup or the whoop of whooping-cough. During 
these distressing attacks the face becomes flushed, congested, or 
livid, according to the severity of the attack, and the veins of 
the neck are distended. In extreme cases the spasm does not 
relax and the child dies in convulsions. 

These attacks may follow each other rapidly, or one only 
may occur at long intervals, and the child appears in excellent 
health between the attacks. They occur usually at night, 

(459) 



460 DISEASES OF THE EAR, NOSE, AND THROAT. 

waking the child out of a sound sleep. They are not accom- 
panied by fever or cough, but there is copious perspiration. 
Children under 2 years of age are most frequently subject 
to this disease, and boys are attacked more often than girls. 
Those whose systems are impoverished are the most likely to 
suffer. 

Diagnosis. — Spasmodic croup does not closely resemble 
any other disease except true croup, from which it can be differ- 
entiated by the absence of fever and false membrane and by the 
presence of good health as soon as the transitory paroxysm 
yields and normal respiration succeeds. 

Prognosis. — When the attacks do not show a high degree 
of intensity of the spasmodic contraction, and when they do 
not last long or do not occur at short intervals, the prognosis is 
usually favorable. But when the closure of the glottis is com- 
plete the child may die of strangulation before help can be 
summoned. The more frequently the paroxysms occur, the 
more danger there is to life. If the spasms are owing to cere- 
bral disease the prognosis is grave. 

Treatment — For immediate relief a few drops of amyl- 
nitrite, ethyl-bromide, chloroform, or ether may be inhaled, if 
any air is inspired. If not, dashing cold water in the face, 
slapping the back of the shoulders, applying ice to the back of 
the neck, tickling the throat, or introducing the finger to cause 
vomiting may succeed in aborting the attack. While the finger 
is in the throat it should be used to learn whether the epiglottis 
is impacted in the aperture of the larynx, and, if it is, the tip 
of the finger should be hooked under the epiglottis and made 
to raise it into position. Drawing the tongue out of the mouth 
also raises the epiglottis. A hot mustard bath may relax the 
spasm. Hypodermatic injections of apomorphine, in very minute 
doses, or a dose of turpeth mineral, 1 or 2 grains, may excite 
vomiting and end the paroxysm. Powdered alum in teaspoon- 
ful doses is a harmless and efficient emetic. 

The cause of the attacks must be ascertained and prophy- 
lactic measures adopted. Laryngitis, indigestion, troublesome 
teeth, or irritation of the genital organs, especially of the pre- 



DISEASES OF THE LARYNX. 461 

puce, may bear a causative relation to this disease. As a rule, 
general tonics, nervous sedatives, and an especially nutritious 
diet are indicated. 

ANOMALIES OF SENSATION. 

Hyperesthesia, neuralgia, and parse sthesia of the larynx 
are most commonly met with in singers and public speakers 
who strain their vocal organs. 

Pathology. — Congestion of the laryngeal mucous mem- 
brane is often present, but inspection may not reveal any appar- 
ent structural change ; this is true when the affection is purely 
of a neurotic character. 

Etiology. — Excessive use of the voice after faulty methods, 
overindulgence in alcoholic beverages, excessive smoking, 
varicose veins and hypertrophied glands at the base of the 
tongue, and inflammatory affections of the larynx occasion hy- 
peresthesia. The causes of paresthesia are quite numerous 
and sometimes obscure. Anything that produces a depressed 
condition of the nervous system may be said to predispose to 
this nervous anomaly. Foreign bodies in the larynx and inflam- 
matory conditions of the mucous membrane cause it. To these 
causes, and to the uric-acid diathesis, neuralgia is due. 

Symptomatology . — The laryngeal mucous membrane is of- 
ten exquisitely sensitive in hyperesthesia, so that dusty or cold 
air, the fumes of a match, smoke, etc., provoke fits of coughing. 
There is usually a sensation of dryness, or scratching, or tick- 
ling in the larynx that excites hemming or slight coughing to 
give relief. Neuralgia here, as elsewhere, is not constant. Fu- 
gitive pains and sensations of soreness of a transitory nature are 
present. In paresthesia there are unusual sensations, generally 
of a foreign body in the larynx. Patients sometimes can scarcely 
be convinced that the impression is not produced by a foreign 
substance. This is called globus hystericus. 

Diagnosis. — There is not much difficulty in deciding upon 
the nervous nature of these affections, since examination gener- 
ally fails to discover any physical signs. The symptoms are 
quite characteristic. 



•162 DISEASES OF THE EAR, NOSE, AND THROAT. 

Prognosis. — These troubles are rather annoying than 
serious. They are persistent, but amenable to treatment. 

Treatment. — If any irritation is found, the throat- tablets — 
containing ammonium chloride, 2 grains ; camphorated tincture 
of opium, compound syrup of squills, and syrup of Tolu, each 
5 minims ; and extract of licorice, 2J grains — may allay the ir- 
ritation and cough. Inhalations of oil of cubebs, carbolic acid, 
salol, and eucalyptus in lavolin, as described under the heading 
of " Sprays and Inhalents," are beneficial. When hypertrophied 
glands and varicose reins are found in the pharynx, and espe- 
cially about the base of the tongue, they are to be eradicated by 
means of the cautery. The bromides and other nervous seda- 
tives and nervous stimulants, like valerianate of ammonia, are 
demanded in certain cases General tonic treatment is often 
necessary, combined with a fattening regimen. 

NERVOUS APHONIA. 

Synonyms. — Hysterical aphonia; hysterical paralysis of 
the vocal cords; functional aphonia. 

Pathology. — This is a functional bilateral paresis of the 
lateral cricoarytenoid muscles, interfering with the normal ref- 
lations of the vocal cords during attempted phonation. They 
cannot be properly approximated. It is not due to any organic 
lesion, but to a temporary loss of the power of muscular 
co-ordination or of innervation. 

Etiology. — This affection is a symptom of hysteria and de- 
bilitating diseases. It occurs most frequently in unmarried 
women, and is especially marked between puberty and the 
establishment of the menopause. 

Symptomatology. — A peculiarity of this disease is that the 
patient may not be able to utter the common conversational 
tone, but may cough or laugh audibly, which does not occur in 
complete paralysis. The onset is sudden, like that of spasmodic 
croup, and the patient cannot attribute it to any cause ; or it 
may follow upon an intense mental impression. Even whisper- 
ing is sometimes out of the question. The attacks are irregu- 
lar, appearing one day and disappearing the next, without any 



DISEASES OF THE LARYNX. 463 

premonitory signs or symptoms. The impression of cold often 
develops the symptoms, and this fact may account for patients, 
exposed to draughts of air at night, losing their voices between 
the hours of retiring and arising. 

Inspection during phonation shows the effect of the loss of 
power of the adductors. The vocal cords cannot be brought 
into close relationship (Plate VIII). Efforts to approximate 
them may cause a spasmodic approaching of the cords, followed 
immediately by their wide separation. Unless a catarrhal con- 
dition exists, the larynx is pale and presents no inflammatory 
appearances. 

Diagnosis. — The history, symptoms, and appearances de- 
scribed render the diagnosis easy. 

Prognosis. — This is favorable, although there is a liability 
of the attacks to return. This is the kind of trouble in which 
the various sorts of "mind-cures" are effective. The mental im- 
pression made by simply introducing any indifferent instrument, 
such as a laryngeal mirror, into the throat may restore the 
voice. In other cases actual treatment must be pursued for a 
considerable time to effect a cure. 

Treatment. — Strychnine, beginning with -^ grain and in- 
creased gradually until its physiological effects are produced, 
and electricity are efficient remedies. Sir Morell Mackenzie de- 
vised a laryngeal electrode for this purpose, by means of which 
one electrode is applied within and the other without the larynx. 
The galvano-faradic current is preferable. If the muscles have 
not become atrophied this treatment is speedily beneficial. 

The elixir of the valerianate of ammonia, combined with 
quinine, if a tonic effect is desired in addition to that of a diffu- 
sive nervous stimulant, meets the indication admirably. Zinc 
valerianate in 1 -grain doses every four hours is recommended by 
Sajous, as well as coca-wine. 

PARALYSIS. 

The laryngeal muscles may be paralyzed singly or in pairs, 
or several muscles may be affected simultaneously. The paral- 
ysis may be unilateral or bilateral, affecting only one side or 



464 DISEASES OF THE EAR, NOSE, AND THROAT. 

both. Anaesthesia of the laryngeal mucous membrane may ex- 
ist as a complication. The paralysis may be of central origin, 
the disease being located in that part of the brain in which the 
laryngeal nerves have their origin, or it may be due to a disease 
in the course of the nerve-trunk. On the other hand, the lesion 
may be of a local character, the muscles being affected either 
primarily, or secondarily to some debilitating systemic malady. 

Pathology. — Cerebral causes of paralysis of the laryngeal 
muscles are : the gummata of syphilis, apoplexy, multiple scle- 
rosis, tumors, etc. Diphtheria is one of the most frequent causes, 
aneurisms in the neck, tumors, progressive bulbar paralysis, hy- 
pertrophied glands, etc., are among the causes. The recurrent 
laryngeal nerve is subject to pressure from aneurism of the arch 
of the aorta, the left carotid, or the subclavian artery. Aneurism 
of the carotid, the subclavian, or the innominate artery on the 
right side may produce the same effect. These conditions re- 
sult in unilateral paralysis, in which the epiglottis cannot be 
completely closed and there is loss of power to extend the 
vocal cord. , When an aneurism or other tumor is large enough 
to occasion pressure on both recurrent laryngeal nerves bilateral 
paralysis results. 

The laryngeal muscles may become the seat of disease 
which, independently of any affection of the nerves, may im- 
pair or destroy their function. An extension of the inflamma- 
tory action from the mucous surfaces to the muscular tissue, 
with exudation and swelling, may produce a paretic condition 
of a transitory nature. Degenerative changes, such as atrophy 
of the muscular tissues, may occur to such an extent as to 
eventuate in muscular paralysis. 

Etiology. — Certain drugs and chemicals cause laryngeal 
motor paralysis, such as the following: Belladonna, opium, 
phosphorus, arsenic, mercury, lead, and alcohol. Such diseases 
as diphtheria, rheumatism, syphilis, anaemia, and inflammation of 
the adjacent areolar tissue and glands are causative conditions. 

When paralysis of the muscles of abduction — the posterior 
cricoarytenoid — occurs, the vocal cords lie in such constantly 
close relation to each other as to present a serious obstruction 



DISEASES OF THE LARYNX. 465 

to respiration (Plate VIII). The breathing is noisy and labored, 
and suffocation is imminent. The voice is not affected because 
of the action of the arytenoideus muscle in approximating the 
vocal bands. When unilateral paralysis of the posterior crico- 
arytenoid muscle takes place there is no dyspnoea except on 
great exertion (Plate VIII). When both sides are affected it 
may be due to brain disease in the region of the fourth ventricle 
or in the medulla affecting the pneumogastric and spinal 
accessory nerves. 

Paralysis of the muscles of adduction — the lateral crico- 
arytenoid — results in the vocal cords remaining in a condition 
of abduction, or separation from each other as far as possible. 
This occurs most frequently in hysteria and leaves no vestige of 
the voice. If this paralysis is unilateral, whispering may be 
possible. 

When paralysis of the arytenoideus muscle happens the 
voice is very feeble or altogether lost. A triangular space be- 
tween the vocal cords, behind the vocal processes, remains dur- 
ing phonation in consequence of the loss of contractility of this 
muscle. 

Paralysis of the muscles of tension — the thyrocricoid and 
the thyro-arytenoid muscles — is not infrequent. Paralysis of the 
thyrocricoid muscles leaves the vocal cords relaxed and uneven. 
They may be seen in contact with each other at irregular inter- 
vals and moving unnaturally, — depressed and elevated in the 
currents of air. The timbre of the voice is changed to a hoarse, 
monotonous quality. The respiration may be more or less em- 
barrassed. Paralysis of the thyro-arytenoid muscles prevents 
approximation of the vocal bands, especially at their centres, so 
that an elliptical aperture remains between them (Plate VIII). 
The voice is feeble, easily wearied, high-pitched, and husky. 
Inordinate use of the voice is the most frequent cause of this 
form of paralysis. 

All three forms of paralysis already described sometimes 
co-exist, — paralysis of abduction, adduction, and relaxation. 
This condition results in total suppression of the voice. The 
vocal bands remain passively half-way between abduction and 

30 



466 DISEASES OF THE EAK, NOSE, AND THROAT. 

adduction, or in the cadaveric position. The usual causes are 
aneurism of the arch of the aorta, goitre, or disease of the 
oesophagus. If a brain disease were the cause, there would be 
loss of sensation and an erect epiglottis, indicative of paralysis 
of the superior laryngeal nerve. There may be unilateral 
paralysis of abduction, adduction, and relaxation, in which case 
but one vocal band assumes the cadaveric position (Plate VIII). 
In this form of paralysis the opposite and unaffected vocal cord 
may perform vicarious function, so that the voice is but little 
roughened in quality ; but, unless the power exists to draw the 
healthy cord beyond the median line to approximate its para- 
lyzed fellow, the voice is seriously affected or destroyed. The 
effort of speaking soon tires the patient, and exertion causes 
labored respiration. 

Treatment. — The wide variation in the nature of the causes 
of laryngeal paralysis renders it impracticable, in a work of 
such an elementary character as this, to deal in detail with all 
of them. Lesions of the nervous centres, of the circulatory 
system, of the apex of the lungs (especially of the right, a 
disease of which may cause pressure on the recurrent laryngeal 
nerve), enlargement of the glands of the neck, inflammation of 
the surrounding tissues and of the laryngeal mucous membrane, 
tumors, and rheumatic and syphilitic conditions call for treat- 
ment adapted to each disease. Drug and chemical poisoning 
must be met with antidotes, restorative measures, and removal 
of the cause. 

Strychnia, internally and hypodermatically, to the degree 
of producing its physiological effects, is valuable. The faradic 
current, applied to the interior and exterior of the larynx by 
the special laryngeal electrode, is efficacious. If the mucous 
membrane of the larynx is sensitive it may have to be cocain- 
ized to admit of the application of the negative pole to the 
interior of the cavity. The current is applied by means of the 
kid-covered electrode, the tip of which must be moistened. By 
the aid of the laryngeal mirror this electrode is carried to the 
points that require the current, while the positive pole is applied 
to the front or sides of the exterior of the larynx. Compound 



DISEASES OF THE LARYNX. 467 

electrodes are made so that both poles may be applied within 
the larynx. Their use is attended with more difficulty than 
presents in the introduction of the single electrode. The 
current is turned on for a few seconds at a time, and repeated 
frequently during a treatment, which is given on alternate days. 
General tonic treatment and appropriate hygienic measures must 
be employed, according to the necessities of each case. 



CHAPTER XLI. 
EASES OF THE LARYNX, CONTINUED. 



Tuberculosis of the Larynx. 

This is one of the most common of laryngeal affections 
and generally proves fatal. It is seldom a primary disease, but 
usually is associated with the same condition in other organs, and 
in such cases is a secondary affection. 

Pathology. — The pathogenic principle of tuberculosis con- 
sists in a micro-organism, — the tubercle bacillus, — which gains 
entrance into the laryngeal tissues by becoming engrafted upon 
an area of mucous membrane denuded of its epithelium. 
Within a few weeks after the development of primary laryn- 
geal tuberculosis the lungs are invaded by the infection; so that 
we witness an intimate reciprocal relation between the various 
sections of the air-passages : laryngeal tuberculosis is most often 
a sequel of pulmonary tuberculosis, and consumption of the 
lungs may develop as a secondary manifestation of tubercular 
infection of the larynx. 

The first changes observable in the larynx are : an unnat- 
ural paleness and tumefaction of the epiglottis, succeeded by a 
superficial, ragged-edged ulceration on the posterior surface of 
the epiglottis, as seen in the mirror (Plate VIII). Multiple 
ulcers soon form in other parts of the respiratory tract, extend- 
ing below to involve the trachea, on the one hand, and upward 
into the pharynx, on the other. The ulcerative process may 
destroy the epiglottis. 

In acute tuberculosis of the larynx the development and 
course of the disease are often so rapid as to result fatally in 
the space of only a few weeks. This is known as miliary tuber- 
culosis. These areas of miliary tubercle are easily made to 
bleed by pressing upon them. The mucosa and submucosa 
become infiltrated, sometimes involving the mucous glands, 
and, as the disease advances, caseous degeneration occurs in 
(468) 






Plate VIII 



PLATE VIII. 

LARYNGOSCOPICAL APPEARANCE OF THE LARYNX, NORMAL 
AND DISEASED.* 



f, 
m, 



Fig. 1. — In Abduction. 
Epiglottis. 
Ventricular baud. 
Vocal band. 
Trachea. 

Cartilage of Wrisberg. 
Cartilage of Santorini. 
Interarytenoid commissure. 



Fig. 2. — In Partial Adduction. 
Omega-shaped epiglottis concealing an- 
terior portion of larynx. 



Fig. 3. — In Complete Adduction. 
Depressed epiglottis concealing two- 
thirds of larynx. 



h 

9, 

w, 

y, 



Fig. 4. — Child's Larynx. 
Glosso-epiglottic fold. 
Palato-epiglottic fold. 
Epiglottis. 
Pyiiform sinus. 
Interarytenoid commissure. 
(Esophagus. 
Posterior wall of pharynx. 



Fig. 5. — Acute Laryngitis. 
Female, set. 25 ; opera-singer. 



Fig. 6. — Acute Laryngitis. 
Female, set. 47. Infiltration ; threaten- 
ing oedema. 

Fig. 7. — Acute Laryngitis. 
Female, aet. 24. Accidental deglutition 
of aq. ammoniae. Spontaneous resolution. 



Fig. 8. — (Edema of Larynx. 
Complete closure of the glottis. 



Fig. 9. — Chronic Laryngitis. 
Female, aet. 36 ; opera-singer. 



Fig. 10 — Chronic Laryngitis Complicated 
with Paralysis of the Arytenoideus. 
Male, aet. 28. 

Fig. 11. — Papilloma of Larynx. 
Mule, aet. 22; stone-cutter. Removed 
with forceps and cauterized base with 
galvano-cautery. 



Fig. 12. — Papilloma of Larynx. 
Female, aet. 5. Tracheotomy. Extir- 
pation with forceps and snare. 



Fig. 13.— Fibroma of Left Vocal Band. 
Male, aet. 63. Removed with forceps. 



Fig. 14. — Fibroma of Bight Vocal Band 
From Mackenzie. 



Fig. 15. — Abductor Paralysis, Bight Side 
During Inspiration. 
Female, aet. 48. Strychnia and iodide 
of potassium. Electricity. 






Fig. 16. — Paralysis of Abduction, Adduc- 
tion, and Bdaxation of Bight Side 
Band in Cadaveric Position. Shoivn in 
Attempted Phonation. 
Female, aet. 61. Due to pressure o: 

goitre upon right recurrent. 



Fig. 17. — Paralysis of Thyro-arytenoid 
Muscles. 
Female, aet. 35 ; singer. Rest and elec- 
tricity. 

Fig. 18. — Bilateral Abductor Paralysis 
of Seven Tears' Standing. 
Male, aet. 47. Treatment proved use- 
less. 

Fig. 19. — Tubercular Laryngitis, 
Female, aet. 24. 



Fig. 20. — Tubercular Laryngitis. 
Male, aet. 50. 



Fig. 21. — Tubercular Laryngitis. 
Male, set. 27. 



Fig. 22. — Syphilitic Laryngitis. 
Male, aet. 24. 



Fig. 23. — Syphilitic Laryngitis. 
Female, aet. 27. 



Fig. 24. — Cancer of the Larynx. 
Epithelioma of left ventricular band. 
From Mackenzie. 



Represented as seen by gaslight. By daylight the red color appears much paler. 



; 




\.Sajous.?inx!t 



Burk & M c Fetnelqe, lith Phiia 



DISEASES OF THE LARYXX. 469 

the tubercles and adjacent tissues. In the acute form of the 
disease the membrane is seen to be congested, instead of pale, 
as is characteristic of the chronic form. 

A peculiarity of this disease is that it may stop short at 
the vocal cords, in its downward course from the pharynx and 
through the larynx, and leave the cords unaffected, although 
the ventricular bands are involved even to the extent of so 
great tumefaction as to completely hide the vocal cords. Some- 
times the latter become thickened to such a degree as to threaten 
suffocation. The processes of infiltration, caseation of the tu- 
bercles, fatty degeneration of the mucous glands, and breaking 
down and melting away of the mucous membrane over these 
tubercular areas proceed until the whole of the interior of the 
larynx may become involved. The destruction continues until 
the cartilage itself becomes ulcerated, necrosed, and disinte- 
grated. As seen in Plate VIII, the cartilages are thickened 
until the indentations separating the cartilages of Santorini and 
Wrisberg are obliterated. The resulting tumefaction appears 
in the shape of a pear. 

Etiology. — Tuberculosis of the larynx is usually consequent 
upon a pre-existing pulmonary consumption, although a primary 
lesion may occur in the larynx, as a result of the reception of 
the tubercle bacillus at a point on the mucous membrane where 
desquamation of the epithelium has occurred. Catarrhal affec- 
tions, exposure to cold and wet and to an irritating atmosphere 
are predisposing causes. In pulmonary phthisis the lodgment 
of the tuberculous sputa from the lungs, as must occur in the 
larynx during expectoration, naturally tends to produce sec- 
ondary points of inoculation. 

Heredity is not emphasized as strongly as it was in former 
years, but inherited tendencies and weakness and a positive 
predisposition to tuberculosis cannot be denied, in the light of 
actual clinical experience. 

Symptomatology. — The visible pathological conditions al- 
ready detailed need not be repeated. The sensations of the 
patient are very positive in their character. Pain is often a 
conspicuous symptom, especially during the act of swallowing. 



470 DISEASES OF THE EAR, NOSE, AND THROAT. 

The voice shows early the presence of a laryngeal trouble, and 
the hoarseness and feebleness may progress until no sound can 
be uttered. 

When the posterior surface of the larynx is ulcerated the 
pain produced by swallowing may be excruciating. Some- 
times the pain reaches to the ears, indicating ulceration of the 
pharyngo-epiglottic folds. 

Difficult respiration is not a common symptom, but may 
result from great swelling of the vocal cords, abscesses, or the 
presence of detached pieces of necrotic cartilages or of tumors. 
One of the most common features of this disease is cough. 
Patients complain of sensations of irritation, at first, described 
as a tickling in the throat or larynx. At this early stage the 
cough is of a hacking character and without expectoration. 
When ulceration takes place or abscesses form, or when pulmo- 
nary tuberculosis is progressing, the cough is attended with 
expectoration. 

Diagnosis. — Generally an examination of the lungs will 
reveal the seat of the primary source of infection. As laryngeal 
tuberculosis may be associated with the same disease of the 
pharynx, inspection of the latter may disclose the nature of the 
malady. The laryngoscopic examination may bring to light the 
patches of miliary tubercle, but these tubercles cannot always be 
distinguished from hypertrophied racemose glands. 

In the early stages this disease is likely to be confounded 
with simple catarrh, but, as the latter yields readily to treatment 
and presents no symptoms of gravity parallel with those of local- 
ized or general tuberculosis, in view of the history of the case, 
habit of body, probable involvement of the lungs, joints, or 
other structures, and the laryngeal appearances, one should 
scarcely err. 

Prognosis. — Occasionally a case recovers ; nearly all die. 
Acute tuberculosis of the larynx kills in a few weeks or months. 
In the secondary laryngeal tuberculosis consecutive to pulmo- 
nary consumption and characterized by caseation with acute 
symptoms, the disease proves fatal in from six to eighteen 
months. These cases may pursue a more chronic course and 



DISEASES OF THE LARYNX. 471 

last from two to four years or longer. It is a difficult matter 
to cause a tuberculous ulcer to heal, and, if it does, it usually 
breaks out again. 

From 10 to 40 per cent, of all patients with pulmonary 
tuberculosis have this laryngeal complication, which shortens 
the duration of their life. 

Treatment. — The treatment given in detail for tuberculosis 
of the pharynx is just as applicable here, and to avoid unneces- 
sary repetition the reader is referred to that article for those 
remedies that are not given here. 

Lennox Browne {Journal of Laryngology, etc.) maintains 
that curettement is not absolutely necessary in this disease. 
Menthol, or menthol with iodol, in spray is best in the pre- 
ulcerative stage. For pain he uses the ethereal solution of aris- 
tol in a spray. Morphia insufflations are used in hopeless cases 
only, but codeia largely, and cocaine before manipulations and 
in advanced dysphagia. Sprays are better that insufflations 
of powders. Excepting for relief of acute dysphagia, he prefers 
applications of the tincture-of-benzoin compound, tincture-of- 
camphor compound, and tincture of belladonna mixed with yelk 
of egg just before food. He employs lactic acid rubbed in with 
considerable force, but not employed previously to ulceration. 
The lactic acid is useless unless preceded by curettement once 
to about every four or six applications of the acid. He curettes 
for the removal of hyperplasia and to clear away the necrotic 
matter when the ulcers are large, and for converting all the 
ulcers into one. 

Desire recommends exalgin twice a day in doses of 4 grains 
as effective in relieving the difficulty of swallowing and pain. 
Wolfenden recommends feeding the patient while lying on his 
stomach while his head depends over the end of the couch, 
which is elevated so as to bring his feet higher than his head. 
He then takes liquid nourishment through a tube from the 
dish placed below his head. 

When abscesses, growths, etc., produce so great obstruction 
to respiration as to threaten suffocation, tracheotomy must be 
done as a last resort. 



472 diseases of the ear, nose, and throat. 

Syphilis of the Larynx. 

Pathology. — Syphilis of the larynx belongs almost always 
to the secondary or tertiary stage. It is first manifested by the 
appearance of a deep blush of congestion of the laryngeal mu- 
cous membrane, characterized by dryness. A little later the 
mucosa becomes swollen by serous infiltration, and this stage is 
soon followed by shallow, ulcerating patches (Plate VIII). The 
changes that take place in the larynx are similar to those de- 
scribed in the pharynx, but the results may be far more serious, 
owing to the diminished calibre of the larynx, which renders 
tumefaction and cicatricial contraction grave affairs. Mucous 
patches are likely to be found associated with the same lesions 
of the pharynx, and occur from three weeks to about three 
months or longer, following the initial sore. They are not 
found below the vocal cords, where there are no papillae. When 
the papillae are attacked they appear as small, red excrescences, 
swelling to the calibre of a small pea and obstructing respiration. 
From a rosy-red color they change to an ashy-gray surrounded 
by a zone of red. They may disappear by the process of ab- 
sorption or ulceration. A sudden infiltration of the mucous 
and submucous tissues is an occasional occurrence, and in this 
situation is of serious import, since the resulting oedema may 
impede respiration to the point of strangulation. 

The tertiary stage is characterized by the presence of gum- 
mata, which become the seat of ulceration. When the erosions 
penetrate deeply into the sub mucosa the invasion of the blood- 
vessels gives rise to haemorrhages. Following these deep ulcera- 
tions are found white, corrugated, contracting cicatrices that 
lessen the lumen of the cavity by their contractions. Adhesions 
of adjoining denuded tissues produce the same effect sometimes 
in a very short space of time. In this manner gross and ob- 
structive deformities of the epiglottis, ventricular bands, and 
vocal cords give rise to a dangerous stenosis of the larynx. 

In the later stages of tertiary syphilis the laryngeal mus- 
cles and cartilages are invaded, with the result of producing 
paralysis, as well as ankylosis and destruction of the cartilages. 



DISEASES OF THE LARYNX. 473 

Etiology. — Syphilis of the larynx is most often a tertiary 
lesion, occurring from three years to a much longer period after 
the initial ulcer. If it exist as a secondary manifestation, it 
follows the primary infection in a few weeks or months, the 
margin of the incubatory period in syphilis being very broad. 
These syphilitic invasions of the larynx are very rarely primary, 
and they are more frequent in men than in women. 

Symptomatology . — As will be seen from the description of 
the pathological appearances in laryngoscopy, the first stage of 
syphilitic laryngitis closely resembles acute laryngitis of the 
simple variety. It may be impossible to distinguish early be- 
tween the two unless a specific history can be obtained. But in 
the syphilitic form of congestion or inflammation the rosy hue 
of the mucous membrane assumes a comparatively mottled ar- 
rangement, which is quite characteristic of this affection. These 
patches of redness are likely to be elevated above the surround- 
ing surface and to show early evidences of beginning erosions 
of a superficial kind. In this period sensations of soreness, 
difficulty of swallowing, and pain appear. The voice begins to 
change in quality ; the pitch is lowered, and a coarse timbre is 
imparted to it. A slight cough makes its appearance, occasion- 
ing little inconvenience, and accompanied by a muco-purulent 
expectoration. 

Inspection shows the picture already described, resembling 
a simple laryngitis. The vocal cords may be involved sufficiently 
to show a congested condition (Plate VIII), which may be bi- 
lateral when one side of the larynx is involved to a greater ex- 
tent than the other. Mucous patches are most frequently found 
on the epiglottis, in the interarytenoid space, and on the ven- 
tricular bands. They do not differ in appearances from those 
described as occurring in the pharynx. Papillomata are occa- 
sionally present, and can be seen as little, wart-like excrescences, 
or they may assume the appearance of yellowish pimples, nearly 
as large as a small pea. The mucous patches may disappear in 
a couple of weeks, when subjected to treatment, and leave a 
blushing area that gradually fades from sight. The condylomata 
may become absorbed or ulcerate away. 



474 DISEASES OF THE EAR, NOSE, AND THROAT. 

In the tertiary stage the epiglottis is most likely to be first 
invaded by the destructive process, ulcerations generally break- 
ing out on the surface next the tongue or on its border. From 
this region they spread to the laryngeal cavity, differing from 
the erosions of the secondary stage in their invasion of the 
deeper layers of the mucous membrane, in the roughened sur- 
faces due to granulation formation, or to the papillomata. The 
ulcers of the secondary stage are superficial patches ; the ulcers 
of the tertiary period are deep-seated and destructive. 

Symmetrical bilateral lesions are characteristic of syphilis. 
When an ulcer forms on one side of the larynx one may confi- 
dently expect to soon find its fellow situated in a corresponding 
area of the opposite side. The irregular, ulcerating surfaces are 
surrounded by a dark-red zone, and are bathed in a purulent 
secretion, which is expectorated in abundance and imparts a foul 
stench to the breath. The cartilages break down and are 
thrown off in the expectoration. The epiglottis may disappear, 
and the particles of necrosed walls of the larynx may drop 
down into the chink of the glottis and threaten suffocation. 
When the deep erosions attack the walls of the blood-vessels 
and destroy their coats, haemorrhages of a serious degree may 
take place. 

Deformities due to swellings, cicatricial contractions, expul- 
sion of parts of the cartilages, and muscular paralysis occur in 
the tertiary stage. Stenosis and consequent embarrassment of 
the respiration may then endanger life. 

Diagnosis. — This disease may be mistaken for tuberculosis, 
and in the early stage may be confounded with a simple catarrhal 
inflammation of the mucous membrane. But the latter yields 
readily to treatment, while the syphilitic disease progresses unin- 
fluenced by any other than specific treatment. 

In tuberculosis serious constitutional disturbances are 
present, such as are not accompaniments of syphilis : fever, 
emaciation, etc. The areas of hyperaemia that later become the 
seat of ulceration are paler and softer in tuberculosis than in 
syphilis. The ulcers of syphilis have more regular, clearly 
denned borders, and are deeper than in tuberculosis. The pain 



DISEASES OF THE LARYNX. 475 

of the latter disease, especially in swallowing, causes great suf- 
fering, while it is not a prominent symptom of syphilis and 
may be absent altogether. The patient improves and gains in 
weight on specific treatment in syphilis, but grows worse in 
tuberculosis. The presence of pulmonary tubercular lesions 
will aid in clearing up the diagnosis. 

Prognosis. — This disease yields most brilliant results except 
in extreme cases of the tertiary type, in which great deformities 
and loss of structure and function occur. 

Treatment — Constitutional remedies alone will often dis- 
sipate laryngeal syphilitic lesions without the introduction of 
local treatment. This disease, therefore, requires less mechanical 
skill in its management than tuberculosis and other affections of 
the larynx. In the early stages mercurials are indicated, while 
in the later periods the iodides are called for, or the mixture of 
the two, which is often more efficacious than the iodides alone. 

The use of the voice, alcoholic stimulants, and tobacco must 
be interdicted, and in the secondary manifestation T a g grain, or 
even more, of the bichloride of mercury may be given thrice 
daily. If the green iodide is employed, -J grain may be used. 
Inunctions of mercurial ointment may be resorted to if the 
stomach reject internal treatment, a drachm being rubbed into 
the skin. In ulcerations a spray of carbolic acid and iodine in 
lavolin, 4-per-cent. solution, is useful when thrown into the 
larynx so as to bathe the ulcerated surfaces. This has mildly 
anaesthetic and alterative effects and answers the purpose of a 
detergent and protective. 

In the tertiary stage the mixed treatment has given the best 
results. I have generally prescribed the mercuric bichloride, 
jig grain, and the potassium iodide, 5 or 10 grains, to be taken 
three or four times a day in 1 drachm of syrup of sarsapanlla. 
The doses are increased in size as tolerance will permit, care 
being taken that the stomach is not deranged by them. The 
ulcerations may require local treatment, such as has already been 
given under the heading of " Syphilis of the Pharynx." J. Solis- 
Cohen's favorite topical application consists of cupric sulphate 
in crystals or in solution, or chromic acid, 1 part in 4 or 10 parts 



416 



DISEASES OF THE EAR, NOSE, AND THROAT. 



of water. Norval H. Pierce has found the following formula 
beneficial to syphilitic ulcers: Iodoform, 1 part; sulphuric 
ether, 10 parts; and albolene, 50 to 100 parts, in the form of a 
spray. 

Paralyses usually yield to the constitutional treatment, but 
it may be advisable to employ electricity and strychnia. 

Contractions and tumefactions may occur sufficiently to 
cause strictures and stenosis of the larynx. If the interference 
with respiration is considerable, the aponeurotic membrane and 
other adventitious tissue must be incised or removed (Fig. 167), 
or they can be divided and destroyed by means of the galvano- 
cautery. When extreme stenosis threatens suffocation, intu- 
bation or tracheotomy must be performed. Since the cicatricial 
tissue of syphilitic origin is little susceptible of dilatation, a 
tube may have to be worn permanently after tracheotomy. 
Schrotter has devised laryngeal dilators to be inserted at first 
by the surgeon and later by the patient. These are left in 
position as long as the patient can endure them, using sizes of 
increasing calibre. They are used daily to increase the lumen 
of the laryngeal aperture, taking from six to eighteen months 
to effect a permanent dilatation. 



CHAPTER XLI1. 

DISEASES OF THE LARYNX, CONCLUDED. 

Tumors. 
For convenience of description, tumors of the larynx are 
considered under two main headings, — " Innocent " and 
"Malignant " tumors. 

Innocent Tumors. 
Benign, or non-malignant, tumors of the larynx arise as the 
result of various kinds of irritation, — such as inordinate use 
of the voice, great exposure to cold and wet weather, inhala- 
tion of air containing much dust, especially of a metallic 
nature, etc. 

PAPILLOMATA. 

Among all the tumors arising in the larynx none are so 
frequently found as these (Plate VIII). They present widely 
differing variations in size and physical appearances. They 
may be of a light- or dark- red color, the size of a bean or less, 
sessile and rough, single or numerous. Others resemble gray 
warts, springing from a vocal cord like little cones. These are 
most common in adult life. Children are often subject to laryn- 
geal papillomata which assume a multiple form comparable to 
the raspberry or cauliflower. They are rapidly regenerated 
after their removal. Indeed, all these varieties may recur, but 
they may be very slow in recurring, or they may not be repro- 
duced at all. 

FIBROMATA. 

These growths are generally found on the vocal cords 
(Plate VIII). They may be attached by pedicles, are usually 
solitary, smooth, and of a gray or deep-red color. Fibrous 
tumors are more often hard than soft, and grow to about the 
size of a common pea. Their removal is followed by more sat- 
isfactory results than obtain after operations on other tumors, 
for they seldom re-appear. 

(477) 



478 DISEASES OF THE EAR, NOSE, AND THROAT. 

Other very rare specimens of growths may be found in 
the larynx. Polypoid excrescences, such as mucous polypi, or 
myxomata, sometimes make their appearance about the anterior 
commissure. They are attached by peduncles, and have a pale 
or red, smooth surface. Occasionally the epiglottis is the seat 
of a cystic tumor which presents a regular, rounded surface. 

Symptomatology. — The symptoms are those characteristic 
of obstruction to respiration, phonation, and deglutition. Res- 
piration is not interfered with in the early history of a laryngeal 
growth unless it is located in close proximity to the vocal bands 
or unless it is of rapid growth, so as to attain a large size and 
materially encroach upon the lumen of the respiratory space. 
With the increase in the bulk of the tumor, difficulty in respi- 
ration increases until it may end in asphyxia, unless relief is 
afforded. The voice may not be impaired if the tumor is situ- 
ated sufficiently above the vocal cords to prevent any embarrass- 
ment of their vibrations. Should the growth be located on one 
of the vocal cords it acts like a damper, impeding the move- 
ments of the cord in response to the column of air, and, if it 
rest between the cords, it prevents their approximation and not 
only causes dysphonia, or difficulty in the production of the 
voice, but it changes its quality and interferes with respiration. 
The vocal bands then cannot be normally approximated, and 
the breathing-space between the cords is lessened in degree, 
according to the size and shape of the growth. Difficulty in 
swallowing occurs as a result of the location of the tumor 
where it prevents closure and perfect coaptation of the epiglottis 
over the entrance to the larynx. If it is seated upon the pos- 
terior surface of the epiglottis, as it presents in the laryngeal 
mirror, the same effect may be produced, Cough may or may 
not be a symptom, but it may be present as a result of the 
inability to evacuate easily the accumulations of mucus, which 
then act like a foreign body, or in case the tumor is of such a 
kind as to vibrate in the currents of air and thus produce a 
tickling or cough-provoking irritation. Patients with benign 
tumors seldom complain of suffering pain. 

Treatment. — There are numerous methods for the removal 



DISEASES OF THE LARYNX. 



479 



of tumors of the larynx. Forceps, knives, and curettes (Fig. 
167) have been devised for this purpose. Snares, the galvano- 
cautery, and caustics are in general use to effect the same 
results. 

When the growths have not attained a considerable size 
and are not easily engaged in an instrument, chemical caustics 
are applicable. Before any operative procedure the interior of 
the larynx should be anaesthetized with a 20-per-cent. solution 
of cocaine. Chromic acid, preferred by Jarvis, is fused into a 
bead of proper size and shape on the flexible applicator (Fig. 
66) and accurately applied to the surface of the growth. Silver 




Fig. 167.— Tobold's Set of Six Forceps, Knives, etc. 



nitrate can be similarly employed, fused in the same manner on 
the platinum-wire loop of the applicator. 

In making applications of caustics, or in manipulating any 
instruments in the larynx, the operation is carried out by means 
of the laryngeal mirror, so that every movement and the rela- 
tions of all the parts can be closely watched. It must not be 
forgotten that the movements of the instruments in the larynx 
are directly opposite to the movements as seen in the mirror, 
everything being reversed. The utmost care must be exercised, 
or injury will be inflicted on the surrounding tissues that will 
be, perhaps, far more serious than the original trouble. 

Lennox Browne prefers the snare for the removal of growths. 
Dundas Grant has devised guarded cutting-forceps that take as 



480 



DISEASES OF THE EAR, NOSE, AND THROAT. 



firm a grip upon the tumor as Mackenzie's instruments. Much 
care must be exercised that a tumor once severed from its at- 
tachment does not drop back into the larynx as it is being 
removed. Evulsion of laryngeal tumors is preferred by some 
operators. For this purpose the strong forceps of Mackenzie 
afford a firm grip upon the growths (Figs. 158 and 168). 
These instruments are used without great difficulty if the larynx 
is properly anaesthetized. This is accomplished if the cocaine 
solution is applied two or three times at intervals of five min- 
utes. The benumbing effect of cocaine in the larynx is very 
transitory, not extending over ten minutes, so that operative 
measures must not be prolonged without renewed anaesthesia. 




Fig. 168.— Mackenzie's Anteroposterior Laryngeal Forceps. 

When operating in the larynx, one ought always to have 
his tracheotomy instruments at hand, for instances have occurred 
in which spasm of the glottis has immediately followed the pro- 
cedure, necessitating opening the larynx to prevent a fatal 
suffocation. 

Ephraim Cutter was the first to perform laryngotomy for 
the removal of a laryngeal tumor. This must sometimes be 
done when the growth cannot be extracted in the usual way. 
An incision is made into the angle of the thyroid cartilage, the 
tumor removed, and the wound closed. 

Malignant Tumors. 
Malignant growths of the larynx may be classed as epi- 
theliomata and sarcomata. 






DISEASES OF THE LARYNX. 481 



E1MTHELIOMATA. 



These are commonly known as cancers, and are, by far, 
the most frequent of malignant growths in this locality. Bos- 
worth reported, as a result of a collective investigation of the 
subject, that, out of three hundred and thirty-four published 
cases of malignant growths, two hundred and four were 
cancers and one hundred and thirty were sarcomata. 

There is considerable variation in the nomenclature of this 
subject. Browne treats of cancer under two headings : " Epithe- 
lioma " and " Alveolar Epithelioma " (adenoid, scirrhous, or 
encephaloid cancer). These growths may occur as primary 
diseases of the larynx or they may result from an extension to 
this organ from adjacent tissues. Heredity is an important etio- 
logical factor, and any occupation or habit that excites constant 
irritation of the tissues, according to Virchow, may result in 
converting an innocent neoplasm into a malignant growth. 
They usually occur after the fortieth year. 

Symptomatology. — The effect upon speech and articulation 
will depend upon the situation of the tumor. If it belong to 
the intrinsic form, — that is, if it attack the subglottic space, 
the vocal cords, the ventricles, or the ventricular bands, — the 
voice is more or less seriously affected. Should the growth be 
limited to the arytenoid cartilages, the sinus pyriformis, the ary- 
epiglottic folds, or the epiglottis, thus constituting an extrinsic 
laryngeal neoplasm, the voice may not be markedly changed. 
When infiltration extends to include the laryngeal muscles, in- 
terfering with their functions, the voice is altered according to 
the muscles affected. Hoarseness may exist from near the 
beginning of the growth. 

In the intrinsic form not only the voice, but respiration, is 
embarrassed. Cough may not be present until ulceration has 
occurred, when a purulent expectoration occurs. In deep 
erosions, necrotic tissue stained with blood and characterized 
by a very offensive odor appears in the sputa. In the final 
periods of the disease difficult deglutition is present, especially 
in the extrinsic variety of tumor. 



31 



482 DISEASES OF THE EAR, NOSE, AND THROAT. 

Pain, the label of malignant growths, is an invariable 
symptom. It is likely to radiate through the neck into the 
pharynx, and, as occurs in tuberculosis of the larynx, it extends 
to the ear. So constant and conspicuous a symptom is the in- 
volvement of the ear in pain that von Ziemssen considered it 
pathognomonic of laryngeal cancer. The general, appearance 
of the patient after a long duration of the disease corresponds 
to the condition called by that classic alliterative term " cancer- 
ous cachexia." 

Inspection shows the location of the growth. At an early 
date only a thickened or nodular condition of the mucosa may 
appear, of a gray or deep-red color. When the epithelium is 
desquamated and the ulcerative process is established, a gran- 
ular proliferation of tissues springs up about the border of the 
erosion. Fungoid growths are seen sprouting from the surface 
of the ulcer, only to succumb to the necrotic process later. 

Prognosis. — According to Mackenzie, the average duration 
of the encephaloid cancer of the larynx is three years. Browne 
gives twelve months as the limit of life after removal of epithe- 
lioma. The results of tracheotomy are more favorable than 
those of thyrectomy or thyrotomy. No operation cures ; starva- 
tion, haemorrhage, or asphyxia ends life. 

Treatment. — The question of cure does not, at the present 
day, enter into the subject. Life may be prolonged and rendered 
less torturesome. From a humanitarian point of view, if it 
were justifiable under any hopeless circumstances to relieve a 
fellow-being of his misery and despair by the merciful pro- 
duction of euthanasia, cancer of the larynx is the case. Death 
constantly stares his victim in the face, and, what is worse, like 
the burning coal in the eye of Cyclops, pain, in all its variations 
and refinements of torture, converts the patient's world into a 
chamber of horrors. No words can depict the agonies of these 
coughing, choking, strangling sufferers. 

Local anaesthetics and anodynes must be added to deter- 
gents and antiseptics. Sprays of cocaine and morphia in 
ethereal solutions are indicated for the alleviation of pain. 
Aristol and iodoform may be used in the same manner. 



DISEASES OF THE LARYNX. 483 

Chloroform and belladonna liniment may be employed for 
external applications. Steam-inhalations containing conium and 
benzoin may prove grateful. 

One should bear in mind that there is always a possibility 
of a syphilitic taint, which would yield to specific treatment, and 
a trial of the effects of sodium or potassium iodide should be 
made. 

Operative measures may relieve the immediate suffering 
from impending suffocation, and may prolong life for several 
months. In October, 1895, Roswell Park reported a case of 
total extirpation of the larynx for epithelioma. Fourteen weeks 
after the operation the patient presented himself at the clinic 
"the picture of health." Operations within the larynx are 
deprecated by some authorities : Browne and Newman. Gal- 
vano-cauterization produces only temporary benefit. Trache- 
otomy offers the greatest promise of relief from suffocation and 
may prolong life from two to four years. 

SARCOMATA. 

These are very rare tumors of rapid growth, and attain to 
a large size. Their appearances differ widely, sometimes resem- 
bling fibromata or papillomata. Only a microscopical exami- 
nation can give a positive diagnosis. They do not kill as soon 
as epithelioma does, but are destructive of life sooner or later. 
They should be removed by some of the methods already 
described for the extirpation of other tumors. Max Toeplitz 
reports a case of chondrosarcoma cured by intra-laryngeal 
operation {Transactions of the International Medical Congress, 
1890). 

Foreign Bodies in the Larynx. 

During inspiration while eating or in the act of laughing 
foreign bodies are drawn into the larynx, where they find 
lodgment. 

Symptomatology. — The presence of any foreign body in the 
larynx excites most violent coughing and symptoms of strangu- 
lation. If the body is of such a size and contour as not to 
completely fill up the lumen of the canal, breathing may pro- 



484 DISEASES OF THE EAR, NOSE, AND THROAT. 

ceed until the reflex spasmodic efforts at dislodgment succeed in 
expelling the body. When the entrance to the larynx or the 
glottis is completely obstructed, suffocation may take place 
before relief can be obtained, the patient dying in a few minutes. 
Boluses of meat and other soft substances that apply themselves 
closely to the inequalities of the cavity are the most common 
causes of death from foreign bodies. But rough bodies may set 
up such an inflammation before their extraction that cedema of 
the larynx or pneumonia may result. 

If the body is coughed up, considerable soreness and pain 
may be experienced for a few days afterward. Small foreign 
particles sometimes remain for a long time in the larynx before 
being thrown out by coughing or sneezing. They may give 
rise to an irritation that leads to serious lesion of the mucosa. 

Treatment. — The finger can sometimes be made to reach 
and dislodge the body if it is lodged in the vicinity of the 
entrance to the larynx. A common remedy is to slap the 
patient on the back of the shoulders just as he makes an expi- 
ratory effort. Gravity may be brought into play in case of a 
foreign body with some material weight. The patient may be 
held with the feet upward and the head pendent while expulsive 
efforts are made by the patient. 

Sharp-pointed articles penetrate the walls of the larynx 
sufficiently to arrest their onward progress, and the coughing, 
retching, and gagging serve to force them farther into the 
tissues. All the sensitive area should be treated to a 20-per- 
cent, solution of cocaine, and by the aid of a mirror the object 
should be located. Then the laryngeal forceps of Tobold (Fig. 
167) or Mackenzie (Figs. 158 and 168) may be made to grasp 
and extract the offending invader. 

If failure attend the attempt to extract the foreign sub- 
stance, and strangulation is impending, tracheotomy must be 
done without delay. If proper instruments are not at command, 
a pocket-knife will do, and retracting hooks can be improvised 
with safety-pins, hair-pins, or the like until sufficient conveniences 
can be supplied. 



INDEX. 



Abbott, 329, 332 
Abbreviations, 4 

Abscess, cerebral and cerebellar, 117, 138, 
139, 141 

metastatic, 138 

of brain, 117, 138, 139, 141 

of larynx, 454, 455 

of neck, 134, 145, 166 

of nose, 271 

retropharyngeal, 145, 166, 404 

subdural, 137 
Accessory cavities of the nose, diseases of, 

276 
Acoumeter, 22 
Acute otitis externa, 53 
Acute otitis media, 68 

appearances of membrana tvmpani, 
69, 70 

grip as a cause, 68 

leech, artificial, 71 

leeches, 71 

naso-pharynx, 68 

paracentesis membranse tympani, 72 

relief of pain, 71, 72 

treatment, 70 
Acute purulent otitis media, 74 

grip as a cause, 68 

influenza as a cause, 68 

membrana tvmpani, appearance of, 
74, 77 * 

micro-organisms, 74 

treatment, 76 
Adenoid hypertrophy of vault of pharynx, 
298 

ear complications, 298 
Adenomata of pharynx, 298 
Adjustable light, 13, 14 
Age, influence of, in diseases, 3 
Agnew, 169 

Air, compressed, and apparatus, 24-39 
Alkaline sprays, 202 
Amblyopia from nasal disease, 284 
Anaesthesia, local, in nasal surgery, 248 

of pharynx, 407 
Anaesthetics, general, 139, 150, 299 
Angina, catarrhalis acuta, 305 

rheumatic, 313, 316 
Anomalies, of auricle, 46 

of external meatus auditorius, 48 

of sensation in larynx, 461 
Anosmia, 268 
Antiseptic sprays, 198, 202 
Antrum, aditus ad, 144 

mastoid, 157, 160, 162 

of Highmore, 276 



Aphonia, 462 
Applicator, caustic, 124 
Aquseductus Fallopii, 103, 156, 158 
Arnold, J. D., 425 
Arrangement of instruments, 12 
Artificial drum-heads, 127 
Aspergilli in the ear, 56 
Aspirator for the ear, 121 
Asthenopia from nasal disease, 283 
Asthma, 232 

from nasal disease, 244, 261, 270 
Astigmatism from nasal disease, 285 
Asymmetry of nasal bones, 243 
Atmospheric causes of disease, 8-11, 290 
Atomizers, 194 

Atresia, of external auditory meatus, 48, 
58 

nasal, 273 
Auditory canal, 50 

acute inflammation, 53 

boils of, 54 

bony growths, 58 

cerumen, 50 

chronic inflammation, 53 

exostoses, 58 

foreign bodies, 59 

furuncles, 54 

hyperostosis, 58 

imperforate, 58 

malignant disease, 42 

narrowing, 59 

neoplastic closure, 58 

parasitic inflammation, 56 

sequestra, 132 
Auditory nerve, 172 
Aural, fungi. 56 

vertigo, 51, 168, 170, 171, 178 
Auricle, benign tumors of, 44 

cutaneous diseases, 40 

cystoma, 45 

deformities, 46, 47 

eczema, 40 

epithelioma, 42 

frost-bite, 40 

gangrene, 42, 43 

hgematorua, 44 

herpes, 45 

hypertrophy, 46 

inflammatory affections, 40, 44 

intertrigo, 45 

lupus, 41 

malignant disease, 42 

othematoma, 44 

pemphigus, 45 

perichondritis, 44 

(485) 



486 



INDEX. 



Auricle, scroll-deformity, 48 

syphilis, 45 

wounds and injuries, 49, 59 
Auscultation-tube and method of using, 

39 
Automatic tuning-fork, 20 
Autophony. 69, 82 

Babcock, K. H., 358 
Baa. ice-, 147 
Baginsky, 331 

Baldness not a cause of disease, 10 

Bandage, net, 165 

Barclay, Robert, 110 

Becker, B., 361 

Behring, 350, 352, 353 

Bertillon, 225 

Bezold, 74, 128, 129 

Billings, Frank, 370 

Bing's hearing-test, 21 

Blake, Clarence J., 105, 111 

Bleeding, local, in acute otitis media, 71 

Blindness from sphenoid disease, 285 

Boils in the external ear, 54 

Bone, turbinated, inferior, 37, 286 

middle, 37, 286 

superior, 37 
Bone-conduction, 19-21 

in chronic aural catarrh, 91 
Bostock, 215 

Bosworth, Francke H., 240, 447 
Bouchut, 435 
Bougies, Eustachian, 67 
Boxing the ears, 45, 62 
Bracket, adjustable lamp-. 15 
Brain-abscess, 117, 138, 139, 141 
Brannon, John Winters, 359 
Braun, 253 
Broadbent, 225 
Brown, Dillon, 433 
Brown. Moreau E., 241, 254 
Browne, J. Lennox, 310, 344, 345, 362, 

471, 479, 481-483 
Brown-Sequard. on hsematoma, 44 
Burnett, Charles H., 56, 105 
Burns and scalds of the pharynx, 409 

Caisson, effect on ear, 28 

Calcareous degeneration of the middle ear, 

86, 87, 126 
Camphor-menthol, 198 

inhaler, 201, 237 
Canal, external auditory, 50, 103 

Fallopian, 103. 156, 158 

glands, 103 

imperforate, 58 

section of, 103 
Canal is tensoris tympani, 65 
Cancer of pharynx, 401 
Carcinoma, of nose, 262 

pharynx, 401 
Caries and necrosis from middle-ear dis- 
eases, 116. 117, 124, 132 



' Carotid artery, rupture of, in suppuration 
of middle ear, 133 
canal, 135, 159 
Cary, Frank, 440 
Ca-sselberry, William E., 239 
Catarrh, chronic, of middle ear, 79, 86 
exudatiye, 79 

hypertrophic, of the nose, 243 
of the middle ear, sero-mucous, 79 
Catarrh, heredity of, 292 
Catarrh, neryous, 214 
Catarrhal otitis media, acute, 68 
Catheter, Eustachian, 36 

in chronic aural catarrh, 84 
method of using, 30, 37, 38 
Causes of disease, atmospheric, 8-11, 290 
Caustic, applicator, 124 
chemical, 123 
for nose and throat, 246 
Cautery, electric, 245 
Canities, accessory, of nose, 276 
! Cerebellar abscess, 138, 141 
I Cerebral abscess, 138, 140 
Cerumen, impacted and inspissated, 50 
Chapman, J., 241 
Charcot, 176 
Cheatham, William, 241 
Chiari, 253 

Cholesteatoma, of mastoid, 128 
of middle ear, 114, 128 
Stacke's operation, 161 
Chondromata, nasal, 259 
Chorda tympani nerye, 102 
Chorditis tuberosa, 455 
Chorea, of pharynx, 408 

reflex, from nasal disease, 289 
Chronic catarrh of the middle ear, 79, 86 
adhesiye inflammation, 86 
age. 88 

alcohol, effects of, 82, 88 
ankylosis of ossicles, 86. 87, 93, 

95 
atrophic stage, 81, 86, 92 
auditory hallucinations, 174 
auto-aspiration in, 84 
autophony, 82 
calcareous degeneration, 86, 87, 

126 
climatic conditions, 82, 85, 89, 

290 
deafness, 86, 90, 91 
differential diagnosis, 82, 92 
electricity, 99 
Eustachian, catheter, 84 

tube, 82 
excision of membrana tympani 

and ossicula, 105 
exudation, 79 

foreshortening of handle of mal- 
let, 80, 92 
frequency of, 7, 8 
heredity, 88 
hygienic surroundings, 8-10 



INDEX 



487 



Chronic catarrh of the middle ear. hyper- 
emia, 79 
hypertrophic, 79 

injection of liquids, 96, 97 

injection of vapors. 97 

load noises, effects of. 90 

ossicles in. B6 

otalgia, 81 

pain in ear, Bl, 89 

paracentesis, -4 

paracusis. 91 

partial excision of membrana 
tynipani. 104 

peculiar modifications of hearing, 
90. 91 

pneumatic tests. -1. 92 

proliferation. B6 

removal, of membrana tympani 
and ossicles. 105 
staphs. Ill 

retraction of membrana tympani, 
BO, 9-2 

sclerosis. 86 

secretive. 79 

sensations of discomfort. -1. 82, 
89, 90 

statistics, 4-7 

tenotomy of tensor tympani. 105 

tinnitus annum. B8, -9 

tobacco, effects. B8, 175 

uric acid. B8 

vertigo. 90. 94 
purulent otitis media. 112 

antiseptic, powders, 118. 119 
solutions, 117, 120 

appearances of membrana tym- 
pani. 112 

caries and necrosis, of adjacent 
tissues. 114. 116. 124. 132 
of ossicles. 113. 125 

caries of carotid canal. 133 

cause of intra-cranial lesions. 
117. 133 

cerebral abscess from. 117. 133 

cholesteatoma. 114. 128 

excision of drum-head and os- 
sicles. 111. 121. 125 

exfoliation of cochlea, 133 

facial paralysis. 116. 129. 177 

granulations. 115. 122 

mastoid complications. 114 

meningitis. 117. 133. 136 

metastasis. 138 

paralysis, facial. 116. 129 

perforation of the membrana 
flaccida. 113 

phlebitis of lateral sinus and jug- 
ular vein. 133-141 

polypi. 116, 122 

pyaemia. 117, 133 

rupture of carotid artery. 133 

seat of intra-cranial lesions, 117, 
133 



Chronic purulent otitis media, sequela?, 
117. 122 
symptoms. 115 

of brain-abscess, 138 
of sinus-thrombosis. 141 
thrombosis of lateral sinus and 

jugular veins, 141, 142 
treatment. 117 
Chronicity of diseases. 9 
Circumscribed otitis externa. 54 
Cirrhotic rhinitis. 252 
Clark. Sir Andrew. 242 
Classification, of diseases. 4-6 

of occupation, sex. etc.. 3 
Climatic causes of disease. 10. 11. 290 
Clinical records. 3. 23 
Clothing. 210, 294, 318 
Cocaine. 247 
Cochlea. 135 

exfoliation. 133 
Cohen. J. Solis-, 323. 395. 452. 475 
Cold, catching. 305 
Cold in the head. 208 
Compressed air. 24-31 

apparatus. 32-39 

meter. 25 
Congenital deafness. 181 
Conjunctivitis from nasal disease. 283. 285 
Conklin. 223 
Corbin. 433 
Corneal inflammation from nasal disease, 

2-3. 2-5 
Coryza, 208 

tablets. 207. 308 
Cotton-carrier. 17 
Cozzolino. Ill 
Croup. 428 

intubation. 435 

laryngismus stridulus. 431. 432 

membranous, idiopathic. 42^ 

spasm of the glottis. 429 

spasmodic. 459 

spurious. 421 

tracheotomy. 442 

choice of operation, 443 

treatment. 432 
Curettes. 134. 152 
Curtis. H. H.. 241 
Cut-off. compressed air, 26 
Cutter. Ephraim, 480 
Cystoma, of auricle, 45 

larynx, 47^ 



Daervocvstitis from nasal disease, 287 

Daly, W. H.. 241. 277 

Darwin. 229 

Davey. James E.. 133. 241 

Davis. Nathan Smith. 223. 237 

D*Espine. 331 

De Lamalleree. 242 

DeVilbiss. Allen. 140 

Deaf -mutism. 181 



488 



INDEX. 



Deafness, causes of, 65, 69, 82, 90, 115, 
177, 178, 180, 292 
congenital, 181 
following suppuration of middle ear, 

127 
hereditary, 182 
hysterical, 177 
Deformities, of auricle, 46 

of nasal cavities, 270, 273 
Delavan, D. B., 272, 389 
Delstanche, Charles, 85, 96, 117 
Dench, Edward B., 130 
Desire, 471 
Dilators, for nose, 213 

for ear tr< 
Dionisio, 254 
Diphtheria, 328 

age of patients, 332 
bacillus, 329, 330 
diagnosis, 336 

diphtheric exudate, 328, 335 
diphtheroid, 331, 337 
effect, on ear, 336 

eye, 336 
incubative period, 332, 334 
intubation, 435 
microbe, 328 

modes of propagation, 333, 334 
of the nose and naso-pharynx, 336 
prophylaxis, 340, 352-354, 356 
pseudodiphtheria, 331, 337 
symptoms, 334 
treatment, 339 

antitoxin, 350 
hygienic, 340 
internal, 348 
local, 343 

serum therapy, 350 
tracheotomy, 442 
vitality of Klebs-Loffler bacillus, 
331, 333 
Dobell's solution, 202 
Double hearing, 173 
Double retractors, 153 
Douche, nasal, 195, 254 
Drum-head. See Membrana tympani. 
Ducts emptying into nasal meatuses, 282, 

286 
Dysphonia, 478 

Ear, electrodes, 131 

internal, 168 

malformations, 46, 48 

middle, 62, 65, 92, 103 
' noises, subjective, 51, 69, 82, 88, 174 

relation of nose to, 64 , 
Ear-cough, 51 
Ear disease, brain-abscess, 117 

from disorders of nervous system, 172, 
173, 177, 178 

from exanthemata, 68 

from grippe, 68 

from influenza, 68 



Ear disease, from intra-cranial growths, 
179 
from leucocythsemia, 171 
from meningitis, 178 
from syphilis, 172 
Ear- fungi, or mold, 56 
Ebstein, 223 

Ecchondrosis, nasal cavities, 243, 259 
Eczema of auricle, 40 
Ehrlich, 350 

Electricity in aural diseases, 99, 130 
Electrodes, ear-, 131 

Emphysema from Eustachian catheter, 39 
Empyema, of antrum of Highmore, 276 
of frontal sinuses, 280 
of maxillary sinuses, 276 
Engelmann, Eosa, 359 
Enslee, Charles L., 3 
Epiphora from nasal disease, 285, 287 
Epistaxis, 255 

plugging nares, 256 
Epithelioma, of ear, 42 
of larynx, 481, 483 
of nose, 262 
of pharynx, 402 
Erectile tuniors of nasal cavities, 259 
Ethmoid sinuses, diseases of, 278 
osteoma, 279 
polypi, 279 
Eustachian, catheter, 36 

emphysema from use of, 39 
method of using, 37 
salpingitis, 64 
tube, 64, 65, 135 

canalis tensoris tympani, 65 
cartilage of, 65 
fossa of Kosenmiiller, 37 
isthmus, 65 
membranous part, 65 
orifice, 37, 65 
patency, 67 
stenosis, 67 
Ewing, 364 
Examination of patients, 12, 189, 415 
Exanthemata, effect on ear, 9 
Excision, of membrana tympani and os- 
sicula, 105, 107, 111, 121 
partial, of membrana tympani, 103 
Exostoses, of auditory canal, 58 

of nasal cavities, 260 
External ear, 40 

auricle, 40 
Exudative catarrh of middle ear, 79 
Eye diseases from diseases of the nose, 282 



Facial expression in diseases of the nose 

and throat, 298 
Facial paralysis, 116, 129, 163, 177 
Faith, Thomas, 39 
Fallopian canal, 103, 156, 158 
False hearing, 91, 173 
Farcy, 266 



INDEX. 



489 



Fatality of chronic suppuration of the 

middle ear, 112, 133, 138, 141 
Faulkner, 240 
Fenestra, oval is, 162 

rotunda, 113 
Fibroids, of larynx, 477 

of nasal cavities, 258 
Floor of the tympanum, 103 
Folds of membrana tympani, 18 
Foreign bodies in ear, 59 

in larynx, 483 

in nose, 273 

in pharynx, 410 
Fork, automatic tuning-, 20 
Fossa of Rosenmuller, 37 
Foster, 357 
Fournier, 398 
Fracture, of base of skull, 180 

of nose, 272 
French, J. M., 272, 369 
Frequency of disease, relative, 3, 7, 8 
Frontal sinuses, diseases of, 280 

transillumination, 281 
Frost-bite of auricle, 40 
Fruitnight, 433 
Fungi, aural, 56 
Furuncles, of ear, 54 

of nose. 267 



Galton's whistle, 21, 22 

Galvano-cautery, 245 

Ganglion, sphenopalatine. 216 

Gelle, 111 

Gelle's hearing-test, 21 

General considerations, 3 

Glanders. 266 

Glasgow. W. C. 240, 395, 433 

Gleason, on sclerosis, 110 

Glenoid fossa, 157 

Globus hystericus, 408, 411 

Glottis, spasm of, 459 

Gluck, I., 241 

Gonorrhoea, nasal, eye symptoms, 285 

Gottstein, 433 

Gouges, 151 

Gouguenheim, 242, 378 

Gould, 288 

Gout, as a cause of hay fever, 222 

effect on the ear, 88 
Gouty sore throat, 313, 316 
Gradle, Henrv. 124, 241, 283, 356 
Grant, J. Dundas. 97, 433, 479 
Granulations, in suppuration of the middle 
ear. 115, 122 

of vocal cords. 455 
Gray. L. C. 227 
Greene, 105 

Greene's mouth-gag, 299 
Grippe, 203 

cause of otitis media, 68, 206 

effect on ear, 90, 206 
Gruber, Josef, 24, 170 



Gummata, of larynx, 472 

of pharynx, 397 
Gunn, Moses, 277 
Guttmann, 349 
Guye, 176 

Hematoma, of auricle, 44 

of nose, 271 
Haemorrhage, of internal ear, 170, 180 

nasal, 255 
Hagenbach, 363 
Haig, Alexander, 222, 223, 225-227, 

238 
Haight, Allen T., 282 
Hall. Marshall, 459 
Hallucinations, auditory, 174 
Hamilton, 288 
Hanau, 380 

Hardie, T. Melville, 241 
Hare, 359 
Hartmann's, inflation experiments, 29 

tuning-forks, 19, 20 
Hay fever, 214 

etiology, 229 

gout. 235 

medical opinions, 239 

nasal disease in, 219 

neurosis. 216 

symptomatology, 231 

treatment, 234 

uric acid, 222 
Head-mirror, 13 
Hearing, double and false, 173 

instruments, 184 

tests of, 18 
Henoch, 331 

Hereditary deafness, 88, 182 
Herpes of auricle, 45 
Heryng, 281, 394 
Higiimore. antrum of, 276 
Hollister, J. H., 369 
Holmes, C. R., 156-164 
Hooks, double mastoid, 153 
Horsier. 140 
Hubbard, Thomas, 402 
Hutchinson, 171 
Hydrorrhea, 211, 231 
Hyperaudition, 173 
Hyperesthesia acoustica, 173 
Hyperesthesia, of larynx, 461 

of nose, 231 

of pharynx, 406 
Hyperostosis in auditory canal, 58 
Hyperplasia, nasal cavities, 243 
Hypertrophy of auricle, 46 
Hypertrophies, nasal cavities, 243 

posterior, surgery of, 299 
Hysterical, deafness, 177 

aphonia, 462 

Ice-bag, 147 

Incision of membrana tympani, 101-103 



490 



INDEX. 



Incus. 102, 103, 132, 135 

articulation, 102, 103 
Inflation of tympana, 26, 27, 36 

Politzer's method, 28, 29, 35 

Valsalva's method, 29 
Inllators, 29, 36 
Influence, of age on diseases, 3, 5, 7 

of occupation, 3, 5, 7 

of sex, 3, 5, 7 
Influenza, 203 

cause of otitis media, 68, 206 

effect on ear, 90, 206 
Ingals, E. Fletcher, 241, 311, 326, 395 
Inhalents, 198 
Inhalers, 201, 237 
Instruments, ear, 107, 123 

hearing-, 184 
Insufflators, 32, 118 
Internal ear, 168, 180 

anaemia, 168 

aural vertigo, 90, 137, 138, 141, 168, 
170, 171, 178 

concussion of labyrinth, 180 

fracture at base of skull, 180 

haemorrhage, 170, 180 

hyperaemia, 168 

hyperaesthesia acoustica, 173 

hysterical deafness, 177 

leucocythaemic deafness, 171 

Meniere's disease, 170 

new growths, 179 

panotitis, 169 

primary acute labyrinthitis, 168 

suppurative exfoliation, 133 

syphilis, 171 
Intertrigo of auricle, 45 
Intubation of larynx, 435 

Jack, Frederick L., 105 
Jackson, 171 
Jackson, A. Reeves, 227 
Jarvis, 479 
Jewell, J. S., 234 
Joal, 229 
Jones, 121 
Jones, Bence, 235 
Jugular, fossa, 103 

vein, phlebitis of, 141 
thrombosis of, 141 

Karlinski, 357 

Kassowitz, 363 

Keratitis from nasal disease, 285 

Kinnear, B. O., 241 

Kitasato, 350, 355 

Kitchen, 241 

Klebs, Edwin Theodore, 328, 365 

Knife in septum deformities, 251 

Knight, C. H., 240 

Koch, 353 

Koerte, 361 

Korner. 139 

Koeeel, 353, 354 



Kramer, 182 
Krause, 394 

Krieger, George E., 352 
Kruckmann, 380 
Kuh, Edwin J., 240 



Labyrinth, concussion, 180 

injuries, 180 
Labyrinthitis, primary acute, 168 
Lacrymal canal, affection of, from nasal 

disease, 287 
Lacrymation from nasal disease, 284, 287 
Laker, 254 
Lang, 237 

Langerhans, 366, 367 
Laryngeal, paralysis, 463 

spasm, 459 
Laryngismus stridulus, 459 
Laryngitis, acute, 421 
symptoms, 422 
treatment, 424 
atrophic, 453 
catarrhal, 421 
chronic, 446 

treatment, 451 
cedematous, 456 
phlegmonous, 454 
purulent, 456 
rheumatic, 426 
simple, 421 
spasmodic, 423 
stridulous, 423 
suppurative, 454 
syphilitic, 472 
Laryngoscopic image, 418 . 
Laryngoscopy, difficulties of, 415, 419 
Larynx, abscess of, 454, 455 
acute catarrh of, 421 
anomalies of sensation, 461 
chronic catarrh of, 446 
examination, 415 
foreign bodies in, 483 
treatment, '484 

laryngotomy, 480 
tracheotomy, 442 
growths in, 477, 480 
cystomata, 478 
epitheliomata, 481 
fibromata, -477 
mucous polypi, 478 
myxomata, 478 
papillomata, 477 
polypi, 478 
sarcomata, 483 
intubation of, 435 
neuroses of, 459 
aphonia, 462 
hyperaesthesia, 461 
neuralgia, 461 
paralysis, 463 
spasm of glottis, 459 
stenosis, 457, 474, 476 






I! 



INDEX. 



491 



Larynx, syphilis, 472 

tuberculosis, 468 

tumors, 477, 480 

vocal bands, 419 
Lateral sinus, 133 

phlebitis of, 133, 141 

thrombosis of, 141 
Lavolin, 127 
Leeches, 71 
Lees, D. B.. 242 
Leflaive, 224 

Leukaemia, effect on ear, 171 
Lever, 223 
Levy. Robert, 396 
Light for examination, 13-15 
Light-condenser, 13 
Linea temporalis, 157 
Loeb. Hanau W., 249, 388 
Loffler, 328, 347 
Love. I. N., 349 
Lucoe, 95, 96, 128 
Lupus, of the ear, 41 

of the nasal cavities, 266 
Luschka, tonsil of, 292, 298 

MacBride, P., 121, 242 
MacCoy, Alexander W., 405 
MaceAven, 139 

Mackenzie, John Noland, 241 
Mackenzie, Sir Morell, 401, 428, 463, 482 
Maggots in the nose, 275 
Malformations of the ear, 46, 48 
Malignant disease from suppuration of the 

middle ear, 41, 42 
Malignant neoplasms, in nasal cavities. 

261, 262 
Malleus, 63, 102, 103, 132, 135 
fracture of, 100 
ligaments, 63 
Marcy. 224 
Martin. 350 
Massage, otoscope, 14, 16, 92, 94 

treatment, 14-17, 95 
Mastoid, antrum. 157, 160, 162 
cells, 135 
curettes, 152 

disease in acute otitis media, 144 
guide. 152 
hooks, 153 
inflammation. 143 

cholesteatoma, 128 
complications of, 143, 166 
instruments for operation, 150 
operative treatment, 149, 155 
primary, 143 
sclerosis, 144 
operations, 155 

haemorrhage in, 156, 159 
portion, temporal bone, 157-160, 164 
Maxillary sinus, 276 
Mays, Thomas J., 223 
Meatus, external auditory. 50 
internal auditory, 143, 156 



Membrana flaccida, perforations of, 113 
Membrana tympani. 17, 18, 63, 102, 135 

atrophy of, 81, 92 

chorda tympani, 102 

folds, 18, 102 

granulations, 115 

haemorrhage, 62, 63 

hyperaemia, 62 

inflammation, 62 

adhesions, 86, 92, 125, 127 

injuries, 62 

inspection, 16 

massage of, 14-17, 95 

membrana, flaccida, 18, 63 
propria, 18, 63 

paracentesis of, 72, 84, 101 

perforation, 68, 74, 112-114, 126 

pockets, or pouches, 63 

polypi, 116 

position of ruptures, 113 

Prussak's fibres, 18 
space, 63 

retraction of, 66, 80, 92 

rupture of, 62, 74, 180 

shape, 17 

Shrapnell's membrane, 17, 63 

thickening of, 81, 92 

topographical relations, 103 

topography, of outer surface, 17 
of inner surface, 102 

umbo, 17 
Membranous sore throat, 325 
Meningitis, 136 

effect on ear, 178 
Metastasis in suppuration of the middle 

ear, 138 
Meter, air-, 25 

Michael's inflation experiments. 30 
Middle ear. 62. 103, 135 

chronic catarrh of, 79, 86 

gouty and rheumatic diathesis, 88 

instruments. 107. 123 
Migraine, 223 
Mirror, forehead-, 14 

-holder. 14 

throat, 192 
Moisard. 354 
Monod. 354 
Moos, 143, 170, 178 
Mouth-breathing, 293, 298, 380, 447 
Murcliison, 222 
Mutes, deaf-, 181 
Mycomyringitis, 56 
Mycosis, of ear, 56 

of pharynx, 389 
Myringitis, 62, 69 

parasitica, 56 
Myxomata, of larynx, 478 

nasal, 257 

Nares, posterior, plugging in epistaxis, 

256 
Nasal adenomata, 298 



492 



INDEX. 






Nasal, atresia, 273 
carcinomata, 262 
cavities, abscess of septum nasi, 271 

adenoma, 298 

anosmia, 268 

blood-tumors, 271 

bony occlusion, 243 

chondromata, 259 

cold in head, 208 

cystic polypi, 258 

deformities, 270 

deviation of the septum, 270 

ecchondrosis, 259 

erectile tumors, 259 

exostosis, 260 

eye diseases from nasal affections, 
282 

fibrous polypi, 258 

foreign bodies, 273 

furuncles, 267 

glanders, 266 

hyperplasias, 243 

hypertrophies, 243 

lupus, 266 

maggots, 275 

malignant neoplasms, 261, 262 

mucous polypi, 257 

osteomata, 260 

papillomata, 258 

parosmia, 269 

perforations of septum, 271 

polypi, 257, 258 

rhinoliths, 261 

sarcomata, 261 

sense of smell, 268 

supporter for nose, 265 

synechia, 243 

syphilis, 263 

tuberculosis, 263 
disease in hay fever, 219 
douche, 195, 254 

cause of inflammation of the 
middle ear, 68 
haemorrhage, 255 
myxoma, 257 
polypi, 257 
reflex neuroses, 216 
specula, 190 
stenosis, 208 
Naso-pharyngeal diphtheria, 336 
Naso-pharynx, 290 

climate, effect of, 290 

Eustachian tube, 65 

fossa of Rosenmuller, 37 

tonsil of Luschka, 292, 298 
diseases of, in otitis media, 68 

atrophic catarrh, 294 

diphtheria, 336 

examination, 193 

facial expression, 298 

follicular catarrh, 290 

polypi, fibroin ucous, 297 
fibrous, 295 



Naso-pharynx, diseases of, tumors, 297 

voice, 298 
Neck-abscess, 145, 166 
Necrosis of adjacent structures in middle- 
ear disease, 132 
Neoplasms, of larynx, 477 
of nose, benign, 257 
malignant, 261 
Nerve, auditory, 172, 180 
facial, 129, 177 
olfactory, 268, 269, 273 
Nervous catarrh, 214, 231 
Net bandage, 165 
Neuralgia, of larynx, 461 

of pharynx, 407 
Neuroses, nasal reflex, 216 
of ear, 173 
of larynx, 459 
of nose, asthmatic, 232, 244, 261, 270 
chorea, 289 
eye disease, 283 
hypersesthesia, 216 
migraine, 223 
reflexes in the eye, 231 
respiratory, 232 
treatment, 234 
of olfaction, 268, 271 
anosmia, 268 
parosmia, 269 
of pharynx, 406, 408 
Neurotic character of hay fever, 216 
Newman, 483 

Noises in the ear, 65, 69, 82, 88, 174 
Northrup, 428, 440 
Nose, 189 

diseases of, abscess of septum, 271 
accessory sinuses, 276 
affecting the eye, 282 
animate foreign bodies in, 275 
anosmia, 268 
asthma, 244, 261, 270 
carcinoma, 262 
deformities, 270, 273 
diphtheria, 336 
epistaxis, 255 
examination, 189 
foreign bodies, 273 
furunculosis, 267 
glanders, 266 
haematoma, 271 
lupus, 266 
maggots, 275 
nose-bleeding, 255 
ocular symptoms, 282 
ozsena, 252 
parosmia, 269 
polypi, 257 
rhinitis, acute, 208 

chronic, hypertrophic, 243 
simple, 210 
rhinoliths, 261 
sarcomata, 261 
septal perforations, 271 



INDEX. 



493 



Nose, diseases of, sprays, 198 

supporter for bridge and tip, 265 
syphilis, 263 
tuberculosis, 263 
ducts, 282, 286 

examination and instruments, 189 
fractures, 272 
hematoma, 271 
pathological conditions affecting the 

eye, 282 
relation to the ear, 64 
Nose-bleeding, 255 
Nuttall, 358 



Occlusion of nasal cavities, 243 
Occupations, influence of, 3, 5 

classified, 3 
O'Dwyer, Joseph, 432, 435 
OSdema, of eyelids from nasal disease, 283 

glottidis, 456 
Olfaction, neuroses of, 268, 269 
Olfactory nerve, 268, 269, 273 
Ophthalmia, gonorrhoeal, from nose, 285 
Optic nerve, compression of, from sphenoid 

disease, 285 
Ossicles, auditory, 102, 103, 132, 135 
articulation, 102. 103 
caries of, 113, 116, 125 
chronic aural catarrh, 86, 92, 95, 100, 

105, 107 
excision of, 105, 125 
hook, 108 
incudo-stapedial articulation, 102, 

103 
vibrator, 100 
Osteomata, nasal cavities, 260 
Othematoma of auricle, 44 
Otitis, externa, acuta, 53 
chronica, 53 
circumscripta, 54 
diffusa, 53 
parasitica, 56 
media, acuta, 68 

from nasal douche, 254 
paracentesis, 72 
chronica, 79, 86 
purulenta, acuta, 74 
chronica, 112 
Otomycosis, 56 
Otorrhoea, chronic, 112 
Otoscope, massage, 14, 16 
Ozena, 252 

cause of eye diseases, 285 

Palate, 37 
Panotitis, 169 
Papillomata, of larynx, 477 

of nasal cavities, 258 
Paracentesis membrane tvmpani, 72, 84, 

101 
Paracusis, duplicata, 173 

Willisii, 174 



Paresthesia, of larynx, 461 

pharynx, 407 
Paralysis, of auditory nerve, 177 
facial nerve, 116, 129, 177 
larynx, 463 
pharynx, 408 
Parasitic otitis externa, 56 
Park, Koswell, 483 
Parosmia, 269 
Peiper, 225 

Pemphigus of auricle, 45 
Perforation of membrana tympani, 68, 74, 

112-114, 126 
Perichondritis of auricle, 44 
Periosteum separator, 153 
Pharyngeal tonsil, 292, 298 
Pharyngitis, acute, 305 

effect on ear, 307 
treatment, 308 
chronic, 311 
follicular, 322 
herpetica, 325 
in measles, 319 
membranous, simple, 325 
rheumatic, 313, 316 
scarlatina, 320 
small-pox, 321 
syphilitic, 396 
tubercular, 393 
Pharyngomycosis, 389 
Pharynx, 37, 305 

acute inflammation, 305 
burns and scalds, 409 
diphtheria, 328 
effects of nasal disease on, 322 
foreign bodies, 410 
herpes, 325 

malignant disease, 401 
morbid growths, 391 

innocent growths, 391 
fibroma, 391 
papilloma, 391, 392 
malignant growths, cancer, 401 
carcinoma, 401 
epithelioma, 401 
sarcoma, 297 
neuroses, 406 

of motion, 408 
of sensation, 406 
parasitic disease, 389 
uvula, inflammation, 392 
malformations, 392 
Phlebitis of sinuses, 141 
Phlegmonous inflammation of antrum of 

Highmore, 276 
Phlyctenular disease from rhinitis, 283 
Phonograph, 98 

Photophobia from nasal disease, 283 
Pierce, Norval H., 253, 476 
Politzer, Adam, 24, 28, 29, 35, 88, 170, 

172, 178 
Pollen as a cause of hay fever, 229 
Polypi, aural, 122 



494 



INDEX. 



Polypi, cystic, nasal, 258 

mucous, of larynx, 478 

nasal, 257 

naso-pliarynx, 295, 297 
Pomeroy, O. D., 105 
Post-nasal catarrh, 290 
Powders, antiseptic, 118 
Powder-blowers, 54, 118 
Prognosis in ear diseases, 7, 8 
Prophylaxis of acute rhinitis, 210 
Prudden, 328 
Prussak's space, 63 
Pseudomembranous croup, 428 
Psychic influence in hay fever, 215 
Pulling. the ears, 45 
Purulent otitis media, acute, 74 

chronic, 112 

pyaemia in, 117 
Pynchon, Edwin, 11, 343, 345 

Quain, 236 

Quine, William E., 370 
Quinquaud, 223 
Quinsy, 373 

Randall, 45 
Ranke, 432 

Records of cases, 3, 23 
Relative frequency of diseases, 3, 7, 8 
Resection of drum-head, 103, 104 
Reservoirs, air-, 32-35 
Retractors for mastoid operations, 153 
Retropharyngeal abscess, 145, 166, 404 
Rheumatic sore throat, 313, 316, 426 
Rheumatism and gout, effects on ear, 88 
Rhinitis, acuta, 208 
clothing, 210 
complications, 209 

atrophica, 252 

cirrhotica, 252 

hypertrophica, 243 

simple chronic, 210 
Rhinoliths, 261 

Rhinoscopic instruments, 189, 192 
Rhinoscopy, 193 
Rhodes, J. E., 437 
Richey, S. O., 88, 97, 133 
Rinne's test for hearing, 21 
Robinson, Beverly, 241 
Robison, John A., 370 
Roe, John O., 240. 452 
Roof of tympanum, 103, 143 
Rosenmiiller's fossa, 37 
Rosenthal, Edwin, 357 
Roux, 328, 350, 351 

Sajous, Charles E., 241, 354, 394, 401, 455, 

463 
Sarcoma, of larynx, 483 

of nose, 261, 297 
Saw in nasal deformities, 251 
Scarlatina, pharynx in, 320 
Scheibe, 144 



Schrotter, 476 
Schwartze, 155, 169, 178 
Sclerosis, of mastoid, 144 

middle ear, 86 
Scroll-ear, 48 
Sea-bathing, effect on ear, 
Seiler, Carl, 202, 242 
Seiss, Ralph W., 240, 249, 



68 



250 



Septum, nasi, diseases and deformities, 
270 

knife, 251 

perforation, 211, 271 
Sequels of middle-ear suppuration, 122 
Sequestra from ear. 132, 134 
Serous otitis media, 79 
Sex, influence, in disease, 3 
Sexton, Samuel, 105, 131 
Sherrington, 224 
Shrapnell's membrane, 18 
Shurley, E. L., 239, 453 
Sinus, inferior petrosal, 143 

lateral 133 
Sinuses, accessory, of nose, 276 

ethmoid, 278 

frontal, 280 

maxillary, 276 

sphenoid, 279 
Sinus-phlebitis and sinus-thrombosis, 141 
Small-pox, throat in, 321 
Smell, sense of, 268, 269 
Smith, J. Lewis, 331, 342, 343, 347 
Snare, ear, 122 
Sokolowski, 380 
Solutions, antiseptic, 202 
Sore throat, acute, 305 

chronic, 311 

clergymen's, 322 

common membranous, 325 

gouty, 313, 316 

granular, 322 

measles, 319 

rheumatic, 313, 316 

scarlet fever, 320 

small-pox, 321 
Spasmodic croup, 459 
Spasms of pharynx, 408 
Specula, aural, 14, 15 

Siegle's pneumatic, 94 

nasal, 190 
Speech in testing the hearing, 22 
Sphenoid sinuses, 279 

diseases of, effect on eye, 279, 285 

tumors, 280 
Sphenopalatine ganglion, 216 
Sprays, 198 

for ear, 29, 30, 85 
Spurious croup, 421 
Stacke's operation, 161 
Stapes, 87, 103, 132, 135 

mobilization of, 106, 110 

removal of, 111 
Statistics, 1 
Stenosis of Eustachian tube, 30, 67 



IXDEX. 



495 



Stenosis, of larynx, 457, 474, 476 

of nasal cavities, 208, 232, 244, 253, 
298 
Strabismus from nasal disease, 285 
Stridulous laryngitis, 423 
Straeh, 364 

Synechia of nasal cavities, 243 
Syphilis, of auricle. 45 

internal ear. 171 

larynx. 472 

nasal cavities. 263 

pharynx, 396 
Syphilitic stenosis of larynx. 476 
Syringes, 52 



Tables, statistical, 3 
Talbot, E. S., 46 
Tamponing posterior nares, 256 
Taylor. James L., 365 
Tegmen. mastoidenm, 143, 160 

tvmpani. 103, 143, 160 
Temporal bone, 156-160, 164 

caries of. 132 
Tensor tvmpani. 65 

tendon of, 63 

tenotomy of, 105 
Tests of hearing, 18 

acoumeter. 22, 23 

Bing's test. 21 

expressions for. ID 

Gabon's whistle. 21. 22 

Gelle's test. 21 

Rhine's test. 21 

speech. 22 

tuning-forks, automatic, 20 
Hartmann's. 20 

Weber's method. 20 

whispers, 23 
Thorner. Max, 305. 311 
Thrombosis of sinuses, 141 

and jugulars, 142 
Tinnitus aurium, 65. 69, 82, 88, 128, 174 
Toeplitz. Max. 133. 172. 483 
Tongue-depressor, 191 
Tonsil, calculi. 390 

hypertrophy, of aural, 379 
pharyngeal. 292. 298 

mycosis, 389 

of* Luschka, 292. 298 

pharyngeal, 292, 298 

syphilis. 396 

tuberculosis. 393 
Tonsillitis, acute. 373 

treatment. 377 
Tonsillotome. 383 
Tonsillotomy. 382 
Tonsils, acute inflammation, 373 

chronic inflammation, 379 

adenoids in vault of pharynx, 298 
aural symptoms from, 381 
treatment. EJ82 

anaesthetics, 383 



Tonsils, chronic inflammation, treatment, 
haemorrhage from tonsil- 
lotomy, 387 
hot snare, 388 
tonsillotome, 383 
tonsillotomy, 382 
Wright's electric amygdalo- 
tome. 388 

hypertrophied, 379 

lacunae of, 382 

large. 379 

parasites in, 389 

varieties of inflammation, 373, 380 
Toynbee's auscultation-tube, 39 
Tracheotomy. 442 

choice of operation. 443 

high operation, 443 

■low operation, 445 
Trachoma of vocal cords, 455 
Transfixion needles in nasal hypertro- 
phies, 250 
Tuberculin in tuberculosis, 395 
Tuberculocidin in tuberculosis. 395 
Tuberculosis, effect, dii ear, 115 

nasal cavities. 263 

larynx, 468 

pharynx, 393 
Tumors of antrum. 277 

auricle, 44 

larynx. 477 

nasal cavities, 261, 271. 297 

pharynx, 391 
Tuning-fork, automatic. 20 
Turbinated bodies, 37 
Tvmpanic cavity, 65, 103 

floor of, 103 

inner wall, 103 

mucous membrane, 117 

outer wall, 65, 102 
Tympanum. See Tvmpanic cavity. 
Tyrrell. Shawe, 224 

Umbo of membrana tvmpani, 17 
Uterine reflex neuroses of larynx, 462 
Uvula, 392 

Uvulitis. 392 

Valsalva's inflation. 29. 98 

Vapors, use of. iu ear. 32-34 

Variola, pharynx in, 321 

Vegetable parasites in ear, 56 

Veilon, A., 373 

Velum palati, 37, 397 

Vertigo. 90. 137, 138, 141, 168, 170, 171, 

178 
Vestibule, 156, 158 
Vibrator, ossicle. 100 
Virchow, Rudolph, 331, 379, 481 
Visual field, contraction from nasal dis- 
ease, 289 
Vocal cords, granulations of, 455 
trachoma, 455 
i Voice in nasal disease, 211, 298 



4<n; 



INDEX. 



Volpius, 14(5 

Wagner, Clinton, 208 
Watch-test for hearing, 18 

Wax in ear, 50 

Weber's test for hearing. 20 

Webster, 189 

Welch, W. H., 328, 358, 368 

Whisper-test for hearing, 22 



Whistle, Gal ton's, 21, 22 
Wilde's incision, 148 
Wile, William C, 343 
Wolfenden, Norris, 379, 471 
Wright, Jonathan, 240, 272, 388 
Wurdemann, H. V., 94, 106 
Wvman, Morrill, 218 

Zaufal, 141 



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